D.

Cephalocaudal Assessment

Assessment Actual Findings Normal Findings Clinical Significance

Procedure
INTEGUMENTA
RY
Skin Inspection reveals Pallor skin is seen in
I: color, Skin color brown evenly colored skin arterial insufficiency,
uniformity edema, absence of scars tones without decreased blood
lesions unusual or supply, and anemia.
P: moisture, prominent Jaundice mostly
temp., turgor discoloration. results from liver
problem.

Edema Absence of edema Skin rebounds and .

does not remain
indented when
pressure is
released.
Temperature Warm to touch Skin is normally a Cold skin may
Normal Temp w/c is warm temperature. accompany shock or
37 degree celcius hypotension. Cool
skin may accompany
arterial disease. Very
warm skin may
indicate a febrile state
or hyperthyroidism.

Hair -The hair is evenly

I: evenness of Upon inspection, the distributed Nutritional
growth, hair of the patient is -the scalp should deficiencies may
thickness, thick. be non- tender cause patchy gray
texture, oiliness, -the scalp is clean hair in some clients.
infection or During palpation, the and dry without
infestation, body scalp is non tender. lesions
hair
P: smoothness

Body hair Normal growth of Varying amounts of If there is excessive

body hair. terminal hair cover generalized hair loss,
the scalp, axillary, it may occur with
body, and pubic infection, nutritional
areas according to deficiencies, hormonal
normal gender disorders, thyroid or
distribution. liver disease, drug

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 toxicity, hepatic or
renal failure or a result
from chemotherapy.
P: smoothness Smooth and firm hair Hair is smooth and As people age, hair
firm, somewhat feels coarser and
elastic. drier.
Nail
I: plate shape Rounded nail shape, Round or square If there is an early
P: Blanch test 160-degree angle nail shape clubbing (180-degree
Upon blanch test, the according to the angle w/ spongy
color of the nail cuticle. There is sensation) and late
return to its normal normally 160-clubbing(greater than
color which is pinkish degree angle180-degree angle)
red in less than 1 between the nail can occur from
second. base and the skin. hypoxia. Spoon nails
may be present w/
iron deficiency
anemia.
texture Thick nails in hands Nails are hard and Thickened nails
and toenails. basically immobile. (especially toenails)
Dark-skinned may be caused by
clients may have decreased circulation.
thicker nails.
Surrounding Soft tissue and intact Soft tissue and The cuticle provides
tissue skin. without any lesions. protection.
HEAD
Skull and Face Upon inspection, the
I: size, shape, shape of the head is - The shape of the If there is acromegaly,
symmetry symmetrical, no head is symmetrical. the skull and facial
:facial features edema are No presence of bones are larger and
:eyes for edema inspected. edema. thicker because of
and hollowness increased production
In palpating the of growth hormone.
patient’s face, there
P: nodules, are no masses,
masses, nodules or any
depressions depressed part,
tenderness, all facial
features is within
normal and is
properly positioned.
…
shape, Symmetric and oval Shapes of skull Acorn-shaped,
symmetry in shape. vary. Head is enlarged skull bones
symmetric, round, are seen in Paget’s
erect and in disease of the bone.

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 midline.
: facial features When I saw her she Facial features are When there is poor
welcome me a big symmetric with eye contact clients are
smile . movement. Client depressed. An
establishes good expressionless,
eye contact when masklike face is
conversing with common in
others. Parkinson’s disease.
An inappropriate facial
expression may
indicate mental
illness.
: eyes for In inspecting the Absence of edema Presence of
edema and eyes, the color of the and hollowness hollowness may be
hollowness eyes are dark brown, due to lack of sleep or
cornea is clear, no rest, and stress.
unnecessary eye
movements, and is
symmetrical to each
other; eyebrows are
thin and evenly
distributed.

P: nodules, Absence of nodules Absence of If there are lesions or

masses, masses or nodules, masses, lumps on the head, it
depressions depression. or depression. may indicate recent
trauma or cancer.
Eyes and
Vision Evenly distributed Aligned, evenly Their function is to
I: Eyebrows for hair in the eyebrows, distributed hair, fine protect the eye from
distribution and aligned, fine and able and able to move sweat and rain, and it
alignment, to move. eyebrows. is also used as a
quality and facial expression.
movement.
: Eyelashes Eyelashes are evenly Eyelashes are If there is an inverted
for evenness of distributed and evenly distributed eyelash, it could
distribution and curved outward along and curved outward cause pain and injure
direction of curl. the lid margins. along the lidthe cornea as the
margins. eyelash brushes
against the
conjunctiva and
cornea.
: eyelidsfor The color of her Eyelids depend on If there is presence of
surface eyelids is light-brown the color of skin lesions or swelling it is
characteristics like the color of her tone, absence of caused by trauma.
skin. Absence of swelling, lesions

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 swelling, lesions, and and discharges.
discharges.
position in Eyelids are Upper lid margin If drooping of the
relation to symmetrically aligned should be between upper lid, (ptosis) it
cornea w/ the cornea. the upper margin of may be attributed to
the iris and the oculomotor nerve
upper margin of the damage, myasthenia
pupil. The lower lid gravis, weakened
margin rests on the muscle or tissue, or a
lower border of the congenital disorder.
iris.
ability to blink She has the ability to The upper and Failure of lids to close
and frequency blink. lower lids close completely puts client
easily and meet at risk for corneal
completely when damage.
closed.
: bulbar Bulbar conjunctiva If there is generalized
conjunctiva for Upon inspection and is clear, moist, and redness, it suggests
color, texture, palpation, the upper smooth. Underlying conjunctivitis.
and lesion. palpebral structures are
conjunctiva are pink clearly visible.
in color and clear Sclera is white and
without lesions absence of lesions.

Palpebral The lower and upper The lower and A foreign body or
conjunctivafor palpebral conjunctiva upper palpebral lesion may cause
color, texture, is clear and free of conjunctiva is clear irritation, burning, pain
and lesion swelling or lesions. and free of swelling and/or swelling of the
or lesions. upper eyelid.
I/P:lacrimal Absence of edema or No swelling or Swelling may be
gland tenderness. Able to redness should caused by blockage,
sac,nasolacrim tear in a right amount appear over areas infection, or an
al duct for as stated by the of the lacrimal inflammatory
edema, client. gland. No drainage condition. Excessive
tenderness/ should be noted tearing may indicate a
tearing from the puncta nasolacrimal sac
when palpating the obstruction.
nasolacrimal duct.
I: corneafor The cornea is clear, The cornea is If there is area of
clarity, texture smooth and sensitive transparent w/ no roughness or dryness
and sensitivity to light. opacities. The on the cornea, it is
oblique shows a often associated w/
smooth and overall injury or allergic
moist surface. responses.

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 direct and The normal direct The normal direct It is considered
consensual and consensual and consensual abnormal, if pupils do
reaction to light pupillary response is pupillary response not react at all to
constriction is constriction. direct and consensual
papillary testing.
 Visual Normal distant vision Normal distant *Impaired far vision
Acuity(near & acuity is 20/20.vision acuity is (myopia)
far vision test) Normal near visual 20/20. Normal near *Impaired near vision
acuity is 14/14. visual acuity is (presbyopia)
14/14.
 Visual Field Inferior: 70 degrees Inferior: 70 degrees A delayed or absent
Test Superior: 45 degrees Superior: 50 perception of the
Temporal: 90 degrees examiner’s finger
degrees Temporal: 90 indicates reduced
degrees peripheral vision.
 EOM test
Corneal light Parallel alignment of The reflection of If there is an
reflex test both eyes. light on the corneas asymmetric position of
should be in the the light reflex, it
exact same spot on indicates deviated
each eye, w/c alignment of the eyes.
indicates parallel This may be due to
alignment. muscle weakness or
paralysis.
Cover test The uncovered and The uncovered eye The uncovered eye
covered eyes remain should remain fixed will move to establish
fixed straight. straight ahead. The focus when the
covered eye should opposite eye is
remain fixed covered. This finding
straight ahead after indicates a deviation
being uncovered. in alignment of the
eyes and muscle
weakness.
Positions test The eyes are able to Eye movement Failure of eyes to
move symmetrically should be smooth follow movement
with coordination in and symmetric symmetrically in any
all six directions. throughout all six or all directions
directions indicates a weakness
in one or more
extraocular muscles
or dysfunction of the
cranial nerves that
innervates the
particular muscle.
Ears and In inspecting the The ears are evenly Malaligned or low-set
Hearing ears, the auricle is colored. It is equal ears may be seen

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I: auricles for brown in color, in size bilaterally. with genitourinary
color, symmetry symmetrical to each The auricle aligns disorders or
and position other and the tip of with the corner of chromosomal defects.
the ear is horizontal each eye and within
to the outer canthus a 10-degree angle
of the eye. of the vertical
position.
: external There is no seen A small amount of *Foul-smelling, sticky,
canal for lesions pus or blood odorless cerumen yellow discharge—
cerumen in the outer canal of is the only otitis externa or
the ears. discharge normally impacted foreign
Upon palpating the present. body.
auricles, it easily
came back to each
original state after
pinching it. There is
no tenderness

lesions, pus Without lesions, pus The canal walls *Bloody, purulent
or blood or blood present as should be pink and discharge—otitis
seen with the use of smooth and without media with ruptured
penlight. nodules. tympanic membrane.
P: auriclesfor The auricles are The skin is smooth A painful auricle is
texture, smooth. It is with no lesions, associated with otitis
elasticity and somewhat elastic lumps, or nodules. externa or a post
areas of and absence of Normally the auricle auricular cyst.
tenderness tenderness. is not tender.
 Rinne’s test to Not performed… Air conduction *With conductive
compare air sound is normally hearing loss, bone
and bone heard longer than conduction sound is
conductions bone conduction heard longer than or
sound. equally as long as air
conduction sound
(BC>AC).
*With sensorineural
hearing loss, air
conduction sound is
heard longer than
bone conduction
sound (AC>BC) if
anything is heard at
all.
NOSE
Upon inspecting the Color is the same Flaring or discharges
I: nose nose, there is no as the rest of the is an abnormal signs.
deviation in discharge, it has two face; the nasal

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shape, size, nostrils are patent, structure is smooth
color, flaring, It is brown in color. and symmetric;
discharge; No nose flaring while
:nasal mucosa breathing.
for redness, Upon palpating the
swelling, growth nose, there is no
or discharge tenderness, masses,
P: tenderness, swelling
masses,
displacements;
: nasal patency
: maxillary and
: frontal
sinuses for
tenderness
Pe: the above
sinuses for
tenderness

: nasal Is able to sniff Is able to sniff Client cannot sniff

patency through each nostril through each nostril through a nostril that
while the other is while the other is is not occluded, nor
occluded. occluded. can he or she sniff or
blow air through the
nostrils. This may be
a sign of swelling,
rhinitis, or a foreign
object obstructing the
nostrils.
: maxillary Frontal and maxillary Frontal and Frontal or maxillary
and frontal sinuses are non- maxillary sinuses sinuses are tender to
sinuses for tender as palpated. are non-tender to palpation in clients
tenderness palpation, and no with allergies or acute
crepitus is evident. bacterial
rhinosinusitis.
Pe: the above Sinuses are not Sinuses are not The frontal and
sinuses for tender on tender on maxillary sinuses are
tenderness percussion. percussion. tender upon
percussion in clients
with allergies or sinus
infection.
Mouth /
Oropharynx Upon inspecting, lips Lips are smooth Pallor around the lips
I: lips for are symmetrical, pink and moist without is seen in anemia and
symmetry of to red in color, no lesions or swelling. shock. Bluish lips may
contour, color, lesion, and not dry. Pink lips are normal result from cold or

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texture, in light-skinned hypoxia. Reddish lips
moisture, lesion In teeth, the patient clients as are bluish are seen in clients
has no dentures, or freckled lips in with ketoacidosis,
teeth are equal. some dark-skinned CO poisoning, and
clients. COPD with
polycythemia.
Swelling of the lips is
common in local or
systemic allergic or
anaphylactic
reactions.
: teeth for In teeth, the patient 32 pearly whitish Clients who smoke,
alignment, loss, has no dentures, teeth with smooth drink large quantities
dental fillings teeth are equal. surfaces and of coffee or tea or
and caries. edges. Upper have an excessive
molars should rest intake of fluoride may
directly on the have yellow or
lower molars and brownish teeth. Tooth
the front upper decay (caries) may
incisors should appear as brown dots
slightly override the or cover more
lower incisors. No extensive areas of
repaired or chewing surfaces.
decayed areas; no Missing teeth can
missing teeth or affect chewing as well
appliances. as self-image.
: gums for Gums have no Gums are pink, *Red, swollen gums
bleeding, color, swelling, lesions. moist, and firm with that bleed easily are
retraction, Sometimes, bleeding tight margins to the seen in gingivitis,
lesions, swelling gums are present tooth. No lesions or scurvy (vit. c
due to her masses. deficiency), and
pregnancy. leukemia.
*Receding red gums
with loss of teeth are
seen in periodontitis.
It is abnormal in
younger clients.
*Enlarged reddened
gums (hyperplasia)
that may cover some
of the normally
exposed teeth may be
seen in pregnancy,
puberty, leukemia,
and use of some
medications, such as

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 phenytoin.
: tongue for Upon inspection, her Tongue should be Among possible
position, color & tongue was pink in pink, moist, a abnormalities are
texture color with white moderate size with deep longitudinal
coloration, moist, and papillae present, fissures seen in
symmetric. There is a and symmetric in dehydration; a black
presence of papillae position. tongue indicative of
on it. bismuth toxicity:
black, hairy tongue; a
smooth, reddish,
shiny tongue without
papillae indicative of
niacin or B12
deficiencies, certain
anemia, and
antineoplastic
therapy.
: salivary Upon inspecting the Absence of swelling Abnormal findings
gland ducts for salivary gland in the and redness in the include lesions,
swelling, lower portion of the client. ulcers, nodules or
redness tongue, there is no hypertrophied duct
redness and openings on either
swelling. side of frenulum.

: palates for Presence of torus The hard palate is A candidal infection

color, shape, palatines in the hard
pale or whitish with may appear as thick
texture, palate. The soft
firm, transverse white plaques on the
presence of palate is pinkish and
rugae. Torus hard palate. Deep
bony smooth while the palatinus is a purple, raised, or flat
prominences hard palate is firmnormal variation lesions may indicate a
and has the
seen more often in Kaposi’s sarcoma
presence of
females, Eskimos, (seen in clients with
transverse rugae. Native Americans, AIDS).
and Asians.
: uvula for The uvula is The uvula is a Asymmetric
position & symmetric and fleshly, solid movement or loss of
mobility moves when saying structure that hangs movement may occur
“aaah”. freely in the after a
midline. No redness cerebrovascular
of or exudates from accident (stroke).
uvula and Palate fails to rise and
symmetric elevation uvula deviates to
of the soft palate. normal side with
cranial nerve X
(vagus) paralysis.

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 : oropharynx Pink and smooth in Pink and smooth in Any deviation in color
for color & texture as inspected texture. is considered
texture by penlight. abnormal.
Neck Muscles Upon inspecting the
patient’s neck, there
I: abnormal is no seen swelling,
swelling or inflammation and the
masses, head patient can move her
movement and head freely. Left to
muscle strength right is 180 degrees.
She can turn up and
down

Chest and  Chest  Chest  Pectus

Thorax symmetric symmetric carinatum
 Skin intact  Lordosis  Pectus
 Chest wall  Thorax is excavatum
intact; no slightly  Kyphosis
tenderness; elliptical in  Scoliosis
no masses shape  Having one
 Absence of  Shoulders at shoulder or
chest pain the same scapula is
 Absence of height higher than the
Dyspnea  Dilated other
 Absence of superficial  Presence of
Orthopnea veins are not dilated
seen superficial
 Respiratory veins
rate is 12-20  Respiratory
breaths per rate greater
minute than 20 breaths
 Normal per
respiration minute(tachypn
are regular ea)
and even in  A respiratory
rhythm rate lower than
 Depth of 12 breaths per
inspiration is minute(bradypn
nonexaggera ea)
ted and  Irregular
effortless respiratory
 Chest wall pattern
intact; no  Orthopnea
tenderness;  Continous
no masses mouth
 Crepitus breathing

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 should be  Presence of
absent pulsation on
 Absence of thorax
chest pain  Presence of
 Absence of thoracic mass
Dyspnea  Presence of
 Absence of crepitus
Orthopnea  A high
 No thoracic diaphragm
tenderness level
 Decrease
breath sound

Cardiovascular Not performed Not performed Not performed

Genitalia Not performed Not performed Not performed
Musculoskelet Body height and Excessively tall or
al weight should be short,or overweight or
appropriate for age underweight
and gender Structural defects
The torso and head Forward slouching of
are upright the shoulders
Walking forward in a Atrophy
straight path Involuntary muscle
Arms swings freely movement
The heel of the foot is Enlargement of joint
well elevated off the Deformity of joint
floor capsule
No observed Hypotonicity
involuntary muscle Spasticity
movement Muscle spasm
Muscle masses
Nodules
Presence of pain and
tenderness
Decrease movement
Elbows that are not
symmetrical
Extra finger, loss of
finger or webbing
A neck that is not erect
and straight
A change in size of the
neck

Cranial Nerves
-I to XII I Olfactory - able to

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smell coffee.

II Optic Vision – pupil

contracts. Light pen
test
Visual acuity using
near card at 14
inches.

III, IV, VI Oculomotor,

Trochlear, Abducens
Eye movement Gaze
in nine directions by
the use of the pen.

V , Vll Trigeminal
Facial – able to show
different expressions
such as frown, smile
and laugh.

VIII
Vestibulocochlear –
able to hear the tick
of the watch.

IX, X
Glossopharyngeal,
vagus – able to
swallow by giving the
patient to drink water.

XI Spinal accessory
–able to shrug on
assessing the
strength of trapezius
muscle.

XII Hypoglossal –
able to extrude
tongue. Move the
tongue up and down
and left and right.

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Neurologic Affect amd mood are Affect/mood:
appropriate to her Appropriate of the
current situation client’s responses
appropriate to
Oriented to time, place situation
and person Mentally alert
(oriented to time,
place, and person)
memory, ability to
follow command,
response to stimulus.

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