General Santos Doctors Medical School Foundation Inc.

Submitted By: Renz N. Pagdato, SN

Name: L. Navarro Marital Status: Married Immunization: Unable to recall

Age/Gender 78 years old female Educational Level: College Graduate Allergies: None

Birthday: February 23, 1939 Occupation: Retired Certified Public Accountant

Religion: Roman Catholic Recent Travel: None

CEPHALOCAUDAL ASSESSMENT

INSPECTION PALPATION PERCUSSION AUSCULTATION INTERPRETATION

SKIN Skin is brown in No masses an Not Applicable Not Applicable A scar results from
Has history of color, blemished tenderness upon the shingles that the
shingles last with the absence palpation. patient had from her
February 2016 of foul odor. Skin past history. Thus,
is dry and scarring is a natural
wrinkled. part of the healing
Scar from process. (Brunner
shingles and Suddart, 2013)
noted at
the upper
right
quadrant
of the
chest.
HAIR The clients hair is No signs of Not Applicable Not Applicable Gray hair is the
No history of any thick, dry white infection or classical signs of
problems hair is evenly infectations. aging. It occurs
distributed. when less
production of melan
which delivers
pigmentation causes
reduction in the
amount of pigment.
(Brunner and
Suddart, 2013)
NAILS The client has When nails are Not Applicable Not Applicable No abnormalities
No history of any light brown and pressed between found
problems has the shape of the fingers, the
convex curve. It nails return to its
is intact. usual color in 2
seconds.
HEAD The head of the There are no Not Applicable Not Applicable No abnormalities
No history of any client is round, nodules, masses found
problems normocephalic and depressions
and symmetrical. when palpated.
EYES There were no There are no Not Applicable Not Applicable No abnormalities
No history of any presence of signs of lesions found
problems discharges, no when palpated.
discoloration and
lids close
symmetrically.
EARS Ears are Soft and paliable Not Applicable Not Applicable No abnormalities
No history of any symmetrical and upon palpation, found
problems in line with the no tender
cantus of the targus.No nodules
eyes. No or swelling noted
discharges except
cerumen noted.
NOSE No septal Both nares are Not Applicable Not Applicable No abnormalities
No history of any deviation noted. patent. . No found
problems Upon tender and
transillumination masses upon
frontal and palpation noted.
maxillary sinuses
are patent
MOUTH AND Lips midline, Paratoid glands, Not Applicable Not Applicable No abnormalities
THROAT symmetrical submandibular found
No history of any andintact. Light glands and
problems brown in color. sublingual glands
Total teeth is 18 are non-palpable
with dentures. and not tender.
Yellow teeth.
NECK Neck has no Supple, non- Not Applicable No abnormalities
No history of any lumps, bulges, or tender. Jugular found
problems masess. vein is not
palpable.
THORAX AND Anterior and Trachea is Resonance to No adventitious No abnormalities
BACK posterior skin is midline. Non eight intercostal sounds, lungs are found
intact and chest tender or no spaces with clear from
expansion is deformities or dullness on the auscultation.
equal. crepitus noted. ribs.
BREAST Breast is Nipples not Not Applicable Not Applicable No abnormalities
No history of any symmetrical with tender. No found
problems no lesions and discharges, lumps
discharge noted. or masses noted.
ABDOMEN Skin color is Soft and non- Upon percussion No bruit and no No abnormalities
No history of any lighter than the tender in all RUQ-dullness venous hums. found
problems rest of the body. abdominal
Skin is intact and quadrant.
without lesions
 noted.
GENITO- Not Assessed Not Assessed Not Assessed Not Assessed No abnormalities
URINARY found
No history of any
problems
EXTREMITIES Posture is erect, Peripheral pulses Not Assessed Not Applicable No abnormalities
No history of any head midline. are palpable. found
problems ROM; flexion,
extension,
abduction,
adduction
performed with
no difficulty.