Documente Academic
Documente Profesional
Documente Cultură
CEPHALOCAUDAL APPROACH
Skin
Normal
Findings
Initial
Assessment
Latest Assessment
No edema, no
abrasions and
other lesions;
moisture in skin
folds and the
axillae (varies
with
environmental
temperature and
humidity, body
temperature,
and activity);
when pinched
skin back to
previous state
(August 3, 2015)
I: Skin is pale in
appearance.
No lesions noted.
P: Dryness of
skin noted. No
nodules
palpated.
P: no
abnormality
noted
A: not applicable
(August 5, 2015)
I: Skin is pale in
appearance. No
lesions noted
P: Dryness of skin
noted. No nodules
palpated
P: no abnormality
noted
A: not applicable
Head
Normal
Findings
Initial
Assessment
Latest
Assessment
Rounded
(normocephalic
and symmetrical,
with frontal,
parietal, and
occipital
prominences;
smooth skull
contour; absence
of nodules and
masses;
symmetric or
slightly
asymmetric facial
features;
palpebral fissures
equal in size;
symmetric
nasolabial folds
I: Normocephalic
in shape and
symmetrical.
Head is in
proportion with
the body.
P: No nodules,
lesions and
masses palpated
No protrusion of
veins noted.
P: No presence of
pain noted while
percussing
A: Not applicable
I: Normocephalic
in shape and
symmetrical.
Head is in
proportion with
the body.
P: No nodules,
lesions and
masses palpated
No protrusion of
veins noted.
P: No presence of
pain noted while
percussing
A: Not applicable
Hair
Normal
Findings
Initial
Assessment
Latest
Assessment
Evenly distributed
hair, thick, silky,
resilient, no
infection or
infestation,
variable amount
of body hair
I: Color of hair is
black and
appears thin and
brittle.
P: Not applicable
P: Not applicable
A: Not applicable
I: Color of hair is
black and
appears thin and
brittle.
P: Not applicable
P: Not applicable
A: Not applicable
Face
Normal
Findings
Initial
Assessment
Latest
Assessment
Symmetric or
slightly
asymmetric facial
features;
palpebral fissures
equal in size;
symmetric
nasolabial folds
I: Face is
symmetrical and
has uniform color
consistency. Skin
pigmentation is
not noted.
P: No nodules or
masses noted
P: Not applicable
A: Not applicable
I: Face is
symmetrical and
has uniform color
consistency. Skin
pigmentation is
not noted.
P: No nodules or
masses noted
P: Not applicable
A: Not applicable
Eyes
Normal
Findings
Initial
Assessment
Latest
Assessment
Eyelids intact, no
discharges, no
discoloration; lids
close
symmetrically;
sclera appears
white; no edema
or tenderness
over lacrimal
gland; pupils
constrict when
looking at near
objects, pupils
dilate when
looking at far
objects, pupils
converge when
near object is
moved toward the
nose
I: Dark brown in
appearance. No
discoloration of
sclera noted. No
presence of
ocular discharges.
Pupil is reactive
to light and
accommodation.
P: Not applicable
P: Not applicable
A: Not applicable
I: Dark brown in
appearance. No
discoloration of
sclera noted. No
presence of
ocular discharges.
Pupil is reactive
to light and
accommodation.
P: Not applicable
P: Not applicable
A: Not applicable
Ears
Normal
Findings
Initial
Assessment
Latest
Assessment
Color is same as
facial skin,
symmetrical;
auricle aligned
with outer
canthus of eye,
about 10 from
vertical, mobile
firm, and not
tender; pinna
recoils after it is
folded; sound is
heard in both ears
I: No discharges
noted. No hearing
impairment.
P: Not applicable
P: Not applicable
A: Not applicable
I: No discharges
noted. No hearing
impairment.
P: Not applicable
P: Not applicable
A: Not applicable
Nose
Normal
Assessment
Initial
Assessment
Latest
Assessment
Symmetric, no
discharges or
flaring; not
tender; no
lesions; mucosa is
pink; nasal
septum intact and
in midline
I: No discharges
or flaring noted
P: No tenderness
noted
P: Not applicable
A: Not applicable
I: No discharges
noted and no
nasal flaring
noted
P: No tenderness
noted
P: Not applicable
A: Not applicable
Throat
Normal Findings
Initial
Assessment
Latest
Assessment
Muscles equal in
size; head
centered;
coordinated,
smooth
movements with
no discomfort
I: No visible mass
and lesions
noted
P: Regular
pulsation noted
P: Not applicable
A: Not applicable
Nails
Convex curvature;
angle of nail plate
about 160;
Smooth texture;
intact epidermis;
prompt return of
pink or usual color
(generally less
than 4 seconds
I: Capillary refill is
4 seconds; no
discoloration
noted
P: Not applicable
P: Not applicable
A: Not applicable
I: Capillary refill
is 4 seconds; no
discoloration
noted
P: Not applicable
P: Not applicable
A: Not applicable
Chest/Thorax
Normal Findings
Initial
Assessment
Latest
Assessment
Chest symmetric,
chest wall intact,
no tenderness, no
masses
I: Use of accessory
muscles when
breathing noted;
Presence of a
pinkish to red
stoma noted
P: No tenderness ,
masses noted
P: not noted
A: 114 cpm.
(August 3, 2015)
I: Use of
accessory
muscles when
breathing noted.
P: No
tenderness ,
masses noted
P: not noted
A: 107 cpm.
(August 5,2015)
Breast
Normal Findings
Initial
Assessment
Latest
Assessment
Rounded shape;
slightly unequal in
size; generally
symmetric; skin
uniform in color,
smooth and intact;
nipples are rounded,
everted, and equal
in size; similar in
color; soft and
smooth; both
nipples point in the
same direction; no
tenderness, masses,
or nodules
I: not noted
P: not noted
P: not noted
A: Not applicable
I: not noted
P: not noted
P: not noted
A: Not
applicable
Abdomen
Normal Findings
Initial
Assessment
Latest
Assessment
I: no abdominal
distention noted.
A: normal bowel
sounds noted
P: not noted
P: No masses
noted; Pain upon
palpation noted
I: no abdominal
distention noted.
A: normal bowel
sounds noted
P: not noted
P: No masses
noted; Pain upon
palpation noted
Normal
Findings
Initial
Assessment
Latest
Assessment
Limbs (Upper
and Lower)
Smooth
coordinated
movements; no
deformities and
swelling
I: No deformities
and swelling
noted
P: No masses or
nodules noted
P: Not noted
A: Not applicable
I: No deformities
and swelling noted
P: No masses or
nodules noted
P: Not noted
A: Not applicable
Foot
Intact skin;
Absence of
swelling or
inflammation;
strong regular
pulses in both
feet
I: Intact skin, no
swelling noted
P: No nodules
noted
P: Not noted
A: Not applicable
I: Intact skin, no
swelling noted
P: No nodules
noted
P: not noted
A: Not applicable
Genitalia
Normal findings
Initial
assessment
Latest
assessment
I: Not noted
P: Not noted
P: Not noted
A: Not applicable
I: Not noted
P: Not noted
P: Not noted
A: Not applicable
I: Not noted
P:Not noted
P: Not noted
A: Not applicable
I: Not noted
P: Not noted
P: Not noted
A: Not applicable
Rectum
Anal sphincter
has good tone
when palpated;
rectal wall is
smooth and not
tender
Anus
Normal
Findings
Initial
Assessment
Latest
Assessment
Intact perianal
skin; usually
slightly more
pigmented than
the skin of the
buttocks; anal
skin is normally
more pigmented,
coarser, and
moister than
perianal skin and
is usually hairless
I: Not noted
P: Not noted
P: Not applicable
A: Not applicable
I: Not noted
P: Not noted
P: Not applicable
A: Not applicable
Normal Findings
Initial
Assessment
Latest Assessment
Normal Findings
Lymphatic Composed of organs that
System
helps maintain
homeostasis by
conserving water and
dissolved substances.
Lymphatic system helps
maintain water balance in
the body. It also protects
the body against
pathogens that may
invade the body.
Initial
Assessment
Latest
Assessment
I: No visible
masses
P: Minimal
enlargement of
lymph nodes
behind earlobes
P: Not noted
A: Not applicable
I: No visible
masses
P: Minimal
enlargement of
lymph nodes
behind earlobes
P: Not noted
A: Not applicable
Respirator
y System
Normal Findings
Initial
Assessment
Latest Assessment
I: No nasal
discharges
noted;
Respiratory rate
of 40 cpm. Use
of accessory
muscles noted.
P:Not noted
P: Not noted
A: Crackles
noted upon
auscultation
I: No nasal discharges
noted; Respiratory rate
of 41 cpm. Use of
accessory muscles
noted.
P:Not noted
P: Not noted
A: Crackles noted upon
auscultation
Cardiovascular
System
Normal Findings
Initial
Assessment
Latest
Assessment
I: Normal chest
contour, blood
pressure is
120/70 mmHg.
(August 3,2015)
P: Rapid pulse
noted
P: Not applicable
A: Cardiac rate
is114 bpm.
( August 3, 2015)
I: Symmetric
chest contour,
blood pressure of
120/90 mmHg.
(August 5,2015)
P: Rapid pulse
noted
P: Not applicable
A: Cardiac rate is
107 bpm.
(August 5, 2015)
Musculo
skeletal
System
Normal Findings
Initial
Assessment
Latest Assessment
I: No deformities
noted, no
swelling noted,
mobile joints
P: No masses
and tenderness
noted
P: Not noted
A: Not applicable
I: No deformities
noted, mobile joints
P: No masses and
tenderness noted
P: Not noted
A: Not applicable
Gastrointestin
al System
Normal
Findings
Initial
Assessment
Latest Assessment
It is the tube
running through
the body from
the mouth to
anus. The role of
digestive system
is to break down
food and deliver
the products to
the blood for
dispersal to the
body cells. The
undigested food
that remains in
the tract leaves
the body through
the anus as
feces.
I: Not
applicable
P: No masses
and tenderness
noted
P: Not noted
A: Not noted
I: Not applicable
P: No masses and
tenderness noted
P: Not noted
A: Not noted
Neurologic
System
Normal Findings
Initial
Assessment
Latest Assessment
I: Alert,
oriented to
time and place.
Responds to
stimuli.
P: No
abnormalities
noted
P:No
abnormalities
noted
A: Not noted
I: Alert, oriented to
time and place.
Responds to stimuli.
P: No abnormalities
noted
P:No abnormalities
noted
A: Not noted
Genitourinar
y
System
Normal Findings
Initial
Assessment
Latest Assessment
The body
produces wastes
as by-product of
its normal
functions, and
these wastes
must be disposed
of. One type of
waste contains
nitrogen, which
results when the
body cell break
down proteins and
nucleic acids. The
urinary system
removes the
nitrogen
containing wastes
from the body in
urine. It is also
called excretory
system.