Cephalocaudal approach
III. Cephalocaudal approachNormal FindingsInitial
AssessmentLatest AssessmentSkinNo 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 notedA: not
applicable(August 5, 2015)I: Skin is pale in appearance. No lesions
notedP: Dryness of skin noted. No nodules palpatedP: no abnormality
notedA: not applicable
Normal FindingsInitial AssessmentLatest AssessmentHead
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 foldsI:
Normocephalic in shape and symmetrical. Head is in proportion with
the body.P: No nodules, lesions and masses palpatedNo protrusion of
veins noted.P: No presence of pain noted while percussingA: Not
applicable
I: Normocephalic in shape and symmetrical. Head is in proportion
with the body.P: No nodules, lesions and masses palpatedNo
protrusion of veins noted.P: No presence of pain noted while
percussingA: Not applicable
Normal FindingsInitial AssessmentLatest AssessmentHairEvenly
distributed hair, thick, silky, resilient, no infection or
infestation, variable amount of body hairI: Color of hair is black
and appears thin and brittle. P: Not applicableP: Not applicableA:
Not applicableI: Color of hair is black and appears thin and
brittle. P: Not applicableP: Not applicableA: Not applicable
Normal FindingsInitial AssessmentLatest AssessmentFace
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 notedP: Not
applicableA: Not applicable
I: Face is symmetrical and has uniform color consistency. Skin
pigmentation is not noted.P: No nodules or masses notedP: Not
applicableA: Not applicable
Normal FindingsInitial AssessmentLatest AssessmentEyesEyelids
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 noseI: Dark brown in appearance. No discoloration of
sclera noted. No presence of ocular discharges. Pupil is reactive
to light and accommodation.P: Not applicableP: Not applicableA: Not
applicableI: Dark brown in appearance. No discoloration of sclera
noted. No presence of ocular discharges. Pupil is reactive to light
and accommodation.P: Not applicableP: Not applicableA: Not
applicable
Normal FindingsInitial AssessmentLatest AssessmentEars
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
applicableP: Not applicableA: Not applicable
I: No discharges noted. No hearing impairment.P: Not
applicableP: Not applicableA: Not applicable
Normal AssessmentInitial AssessmentLatest
AssessmentNoseSymmetric, no discharges or flaring; not tender; no
lesions; mucosa is pink; nasal septum intact and in midlineI: No
discharges or flaring notedP: No tenderness notedP: Not
applicableA: Not applicable
I: No discharges noted and no nasal flaring notedP: No
tenderness notedP: Not applicableA: Not applicable
Normal Findings Initial Assessment Latest AssessmentThroat
Nails
Muscles equal in size; head centered; coordinated, smooth
movements with no discomfort
Convex curvature; angle of nail plate about 160; Smooth texture;
intact epidermis; prompt return of pink or usual color (generally
less than 4 secondsI:No visible mass and lesions noted P: Regular
pulsation noted P: Not applicableA: Not applicable
I: Capillary refill is 4 seconds; no discoloration notedP: Not
applicableP: Not applicableA: Not applicable
I: No visible mass and lesions noted P: Regular pulsation
notedP: Not applicableA: Not applicable
I: Capillary refill is 4 seconds; no discoloration notedP: Not
applicableP: Not applicableA: Not applicable
Normal Findings Initial Assessment Latest
AssessmentChest/ThoraxChest symmetric, chest wall intact, no
tenderness, no massesI: Use of accessory muscles when breathing
noted; Presence of a pinkish to red stoma notedP: No tenderness ,
masses notedP: not notedA: 114 cpm.(August 3, 2015)I: Use of
accessory muscles when breathing noted.P: No tenderness , masses
notedP: not notedA: 107 cpm.(August 5,2015)
Normal FindingsInitial AssessmentLatest AssessmentBreast
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 notedP: not noted P: not notedA: Not applicable
I: not notedP: not noted P: not notedA: Not applicable
Normal FindingsInitial AssessmentLatest AssessmentAbdomenUniform
color; flat rounded (convex), or scapoid (concave) contour;
symmetric contour; audible bowel sounds; absence of arterial
bruits; absence of friction rubI: no abdominal distention noted.A:
normal bowel sounds notedP: not notedP: No masses noted; Pain upon
palpation noted
I: no abdominal distention noted.A: normal bowel sounds notedP:
not notedP: No masses noted; Pain upon palpation notedNormal
FindingsInitial AssessmentLatest AssessmentLimbs (Upper and
Lower)
FootSmooth coordinated movements; no deformities and
swelling
Intact skin; Absence of swelling or inflammation; strong regular
pulses in both feetI: No deformities and swelling notedP: No masses
or nodules notedP: Not notedA: Not applicable
I: Intact skin, no swelling notedP: No nodules notedP: Not
notedA: Not applicableI: No deformities and swelling notedP: No
masses or nodules notedP: Not notedA: Not applicable
I: Intact skin, no swelling notedP: No nodules notedP: not
notedA: Not applicableNormal findingsInitial assessmentLatest
assessmentGenitalia
RectumPubic skin intact, no lesions; labia round, full, and
relatively symmetric; clitoris does not exceed 1 cm in width and 2
cm in length; no inflammation, swelling, or discharge; no
enlargement or tenderness
Anal sphincter has good tone when palpated; rectal wall is
smooth and not tenderI: Not notedP: Not notedP: Not notedA: Not
applicable
I: Not notedP:Not notedP: Not notedA: Not applicableI: Not noted
P: Not notedP: Not notedA: Not applicable
I: Not notedP: Not notedP: Not notedA: Not applicableNormal
FindingsInitial AssessmentLatest AssessmentAnusIntact 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 hairlessI: Not notedP:
Not notedP: Not applicableA: Not applicableI: Not notedP: Not
notedP: Not applicableA: Not applicableIV. System approachNormal
FindingsInitial AssessmentLatest AssessmentIntegumentaryConsist of
skin, hair and nails. Skin provides a physical barrier between
underlying tissues and the external environment; excretion through
perspiration; temperature regulation and sensory perception. Hair
protects the scalp from excessive heat loss. Nails protects the
dorsal tips of fingers and toes and site of assessing the capillary
refill.I: Pale skin and dryness noted, brittle hair, nails are
intact and capillary refill is 4 seconds, normal skin turgor, no
nodules noted. CTT in mid axillary line. ( August 4, 2015)P: No
masses and tenderness noted, normal skin temperatureP: No
abnormalities notedA: Not applicableI: Pale skin and dryness noted,
brittle hair, nails are intact and capillary refill is 4 seconds,
normal skin turgor, no nodules noted. CTT in mid axillary line.P:
No masses and tenderness noted, normal skin temperatureP: No
abnormalities notedA: Not applicableNormal FindingsInitial
AssessmentLatest AssessmentLymphatic System
Composed of organs that 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.I: No visible massesP: Minimal
enlargement of lymph nodes behind earlobesP: Not notedA: Not
applicableI: No visible massesP: Minimal enlargement of lymph nodes
behind earlobesP: Not notedA: Not applicable
Normal FindingsInitial AssessmentLatest AssessmentRespiratory
SystemThe purpose of the respiratory system is to keep the body
constantly supplied with oxygen and to remove the carbon dioxide.
It consists of the nasal passages, pharynx, larynx, trachea,
bronchi, and lungs. Within the lungs are tiny air sacs. It is
through the thin walls of these air sacs that gases are transported
to and from the blood. The normal respiratory rate is 16-20 cpm.I:
No nasal discharges noted; Respiratory rate of 40 cpm. Use of
accessory muscles noted.P:Not notedP: Not notedA: Crackles noted
upon auscultationI: No nasal discharges noted; Respiratory rate of
41 cpm. Use of accessory muscles noted.P:Not notedP: Not notedA:
Crackles noted upon auscultationNormal FindingsInitial
AssessmentLatest AssessmentCardiovas-cular
SystemThe primary organ are heart and blood vessels. Using blood
as the transporting fluid, the cardiovascular system carries
oxygen, nutrients, hormones, or other substances to and from tissue
cells where exchanges are made. The heart acts as the blood pumps,
propelling blood out its chambers into the blood vessels to the
transported to all body tissue. The normal cardiac rate is 60-100
bpm.I: Normal chest contour, blood pressure is 120/70 mmHg.(August
3,2015)P: Rapid pulse notedP: Not applicableA: Cardiac rate is114
bpm.( August 3, 2015)
I: Symmetric chest contour, blood pressure of 120/90
mmHg.(August 5,2015)P: Rapid pulse notedP: Not applicableA: Cardiac
rate is 107 bpm. (August 5, 2015)Normal FindingsInitial
AssessmentLatest AssessmentMusculoskeletal
SystemThe skeletal system serves as the supporting framework of
the body, and it performs several other important functions such as
the body shape, mechanisms of movement, and the erect posture in
humans. Muscle tissue is specialized for contraction. Contraction
of muscle produces the movements of the body and body parts.I: No
deformities noted, no swelling noted, mobile jointsP: No masses and
tenderness notedP: Not notedA: Not applicableI: No deformities
noted, mobile jointsP: No masses and tenderness notedP: Not notedA:
Not applicableNormal FindingsInitial AssessmentLatest
AssessmentGastrointestinal SystemIt 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 applicableP: No
masses and tenderness notedP: Not notedA: Not notedI: Not
applicableP: No masses and tenderness notedP: Not notedA: Not
noted
Normal FindingsInitial AssessmentLatest AssessmentNeurologic
SystemThe nervous system consists of the brain, spinal cord,
sensory organs, and all of the nerves that connect these organs
with the rest of the body. Together, these organs are responsible
for the control of the body and communication among the parts.I:
Alert, oriented to time and place. Responds to stimuli.P: No
abnormalities notedP:No abnormalities notedA: Not notedI: Alert,
oriented to time and place. Responds to stimuli.P: No abnormalities
notedP:No abnormalities notedA: Not notedNormal FindingsInitial
AssessmentLatest AssessmentGenitourinarySystemThe 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.I: The client has
normal voiding pattern.P: not notedP: Not notedA: Not notedI: The
client has normal voiding pattern.P: Not notedP: not notedA: Not
noted
