Scribd
Upload
445 views5 pages

Nursing Assessment in Tabular Form (Repaired) To Be Placed!@#%$!@# #@ @

The nursing assessment found the patient to be in her third trimester of pregnancy. She had normal findings for her skin, hair, nails, head, face, eyes, ears, nose, mouth, neck, chest, abdomen, extremities, and neurological and mental status. Only notable findings were slight edema in the lower extremities due to pregnancy, and anxiety due to fear of labor pain. All physical exam findings were otherwise normal.

Uploaded by

Leo Buquiran Acabal
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
445 views5 pages

Nursing Assessment in Tabular Form (Repaired) To Be Placed!@#%$!@# #@ @

The nursing assessment found the patient to be in her third trimester of pregnancy. She had normal findings for her skin, hair, nails, head, face, eyes, ears, nose, mouth, neck, chest, abdomen, extremities, and neurological and mental status. Only notable findings were slight edema in the lower extremities due to pregnancy, and anxiety due to fear of labor pain. All physical exam findings were otherwise normal.

Uploaded by

Leo Buquiran Acabal
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
You are on page 1/ 5

Nursing Assessment in Tabular Form

Assessment

Findings

Integumentary

Skin

Condition

Pigmentation

-Normal for racial background; pink nail bed.


-Slight edema of lower extremities because
of pregnancy
- Linea nigra
Striae gravidarum
melasma

Hair

Evenly distributed hair.


With short, black and shiny hair.
With presence of pediculosis Capitis.

Nails

Smooth and has intact epidermis


With short and clean fingernails and
toenails.

Skull

Rounded, normocephalic and symmetrical,


smooth and has uniform
consistency.Absence of nodules or masses.

Face

Distort facial movement and appeared


slightly pale and altered due to pain in the
abdomen that is caused by uterine
contraction which is normal during
pregnancy. Palpebral fissures equal in size,
symmetric nasolabial folds.

Eyes and Vision

Eyebrows

Hair evenly distributed with skin intact.


Eyebrows are symmetrically aligned and
have equal movement.

Eyelashes

Equally distributed and curled slightly


outward.

Eyelids

Skin intact with no discharges but with


discoloration due to melasma.
Lids close symmetrically and blinks

Assessment

Findings
involuntary.

Bulbar conjunctiva

Transparent with capillaries slightly visible

Palpebral Conjunctiva

Shiny, smooth, pink

Sclera

Appears white.

Lacrimal gland, Lacrimal sac,

No edema or tenderness over the lacrimal


gland and no tearing.

Nasolacrimal duct
Cornea

Clarity and texture

Transparent, smooth and shiny upon


inspection by the use of a penlight which is
held in an oblique angle of the eye and
moving the light slowly across the eye.
Has [brown] eyes.

Corneal sensitivity

Blinks when the cornea is touched through a


cotton wisp from the back of the client.

Pupils

Black, equal in size with consensual and


direct reaction, pupils equally rounded and
reactive to light and accommodation, pupils
constrict when looking at near objects,
dilates at far objects, converge when object
is moved toward the nose at four inches
distance and by using penlight.

Visual Fields

When looking straight ahead, the client can


see objects at the periphery which is done
by having the client sit directly facing the
nurse at a distance of 2-3 feet.
The right eye is covered with a card and
asked to look directly at the student nurses
nose. Hold penlight in the periphery and ask
the client when the moving object is spotted.

Visual Acuity

Able to identify letter/read in the newsprints


at a distance of fourteen inches.
Patient was able to read the newsprint at a
distance of 8 inches.

Ear and Hearing

Assessment

Findings

Auricles

Color of the auricles is same as facial skin,


symmetrical, auricle is aligned with the outer
canthus of the eye, mobile, firm, non-tender,
and pinna recoils after it is being folded.

External Ear Canal

Without impacted cerumen.

Hearing Acuity Test

Voice sound audible.

Watch Tick Test

Able to hear ticking on right ear at a distance


of one inch and was able to hear the ticking
on the left ear at the same distance

Nose and sinuses

External Nose

Symmetric and straight, no flaring, uniform in


color, air moves freely as the clients
breathes through the nares.

Nasal Cavity

Mucosa is pink, no lesions and nasal


septum intact and in middle with no
tenderness.

Mouth and Oropharynx

Symmetrical, pale lips, brown gums and able


to purse lips.

Teeth

With dental caries and decayed lower molars

Tongue and floor of the mouth

Central position, pink but with whitish


coating which is normal, with veins
prominent in the floor of the mouth.

Tongue movement

Moves when asked to move without difficulty


and without tenderness upon palpation.

Uvula

Positioned midline of soft palate.

Gag Reflex

Present which is elicited through the use of a


tongue depressor.

Neck

Positioned at the midline without tenderness


and flexes easily. No masses palpated.

Head movement

Coordinated, smooth movement with no


discomfort, head laterally flexes, head
laterally rotates and hyperextends.

Muscle strength

With equal strength

Assessment
Lymph Nodes

Thyroid Gland

Findings
Non-palpable, non tender
Not visible on inspection, glands ascend but
not visible in female during swallowing and
visible in males.

Thorax and lungs


Posterior thorax

Spinal alignment

Breath Sounds

Anterior Thorax

Chest symmetrical
Spine vertically aligned, spinal column is
straight, left and right shoulders and hips are
at the same height.
With normal breath sounds without
dyspnea.
Quiet, rhythmic and effortless respiration

Abdomen

Pigmentation changes due to pregnancy


includes linea nigra and striae gravidarum.

Abdominal movements

Fetal movements of pregnancy.

Auscultation of bowel sounds

With audible sounds of 23 bowel


sounds/minute.

Upper Extremities

Without scars and lesions on both


extremities.

Lower Extremities

Slight edema because of pregnancy

Muscles

Equal in size both sides of the body, smooth


coordinated movements, 100% of normal full
movement against gravity and full
resistance.

Bones and Joints

No deformities or swelling, joints move


smoothly.

Mental Status

marked anxiety(fear of pain and prolonged


labor), excitement

Language

Can express oneself by speech or sign.

Orientation

Oriented to a person, place, date or time.

Attention span

Able to concentrate as evidence by


answering the questions appropriately.

Level of Consciousness

A total of 15 points indicative of complete

Assessment

Findings
orientation and alertness.

Motor Function

Can squat if told to. active

Gross Motor and Balance

Walking gait

Has upright posture and steady gait with


opposing arm swing unaided and
maintaining balance.

Standing on one foot with eyes closed

Maintained stance for at least five (5)


seconds.

Heel toe walking

Maintains a heel toe walking along a straight


line

Toe or heel walking

Able to walk several steps in toes/heels.

Fine motor test for Upper Extremities


Finger to nose test

Repeatedly and rhythmically touches the


nose.

Alternating supination and pronation of


hands on knees

Can alternately supinate and pronate hands


at rapid pace.

Finger to nose and to the nurses finger

Perform with coordinating and rapidity.

Fingers to fingers

Perform with accuracy and rapidity.

Fingers to thumb

Rapidly touches each finger to thumb with


each hand.

Fine motor test for the Lower Extremities


Pain sensation

Able to feel pain specially in the abdomen


and lower back due to uterine contraction
caused by pre-term to full-term labor.

You might also like