CEPHALOCAUDAL ASSESSMENT

Fundamentals of Nursing
1/22/2013 Submitted to: Ms. Azenith Lupig RN., MAN. Submitted by: Apryll Rose Mayo

SKIN Assessment Procedure Inspection Inspect general skin coloration Inspect for color variations Normal Findings Evenly colored skin tones without usual or prominent discoloration. Some clients have suntanned areas, freckles, or white patches known as vitiligo. Variation is due to different amount of melanin. Skin is intact, and there is no reddened areas Without lesions Actual Finding Skin is pale in appearance Significance Pallor is seen in arterial insufficiency, decreased blood supply and anemia. Erythema is seen in inflammation or trauma

Check for skin integrity Inspect for lesions

Skin breakdown may progress to ulcer Lesions may indicate local or systemic problem

Palpation Assess texture Assess thickness Skin is smooth and even Skin is normally thin but calluses are common on the areas exposed to pressure. Skin is rough Roughening of the skin may be a sign of dehydration Very thin skin may seen in client with arterial insufficiency

Assess moisture

Skin moisture may vary from moist to dry depending on the area. Skin pinches easily and returns to its position. Skin rebounds and does not remain indented when pressure is released. Poor skin turgor Edema in the lower extremeties

Diaphoresis may occur with fever or hypothyroidism Seen in dehydration Decreased mobility may be seen in edema Due to renal failure

Assess mobility and turgor Detect edema

SCALP AND HAIR Assessment Procedure Inspection and Palpation Inspect for general color or condition Normal Findings Hair color if from pale blond to black to gray to white. Color of the scalp determined by the amount of melanin present Scalp is clean and dry. Dandruff may be visible. Hair is smooth and firm, somewhat elastic Actual Finding Hair is color black and scalp is white Significance Nutritional deficiency may cause patchy gray hair

Palpate the hair and scalp for cleanliness, dryness parasites and lesions

Hair is rough or not in good condition

Indicates dhn.

HEAD AND NECK Assessment Procedure Inspection Inspect the head Normal Findings Head is symmetric, round and erect and in midline. No lesions. Neck is symmetric with head centered and without masses. Head is hard and smooth without lesions Elastic and non-tender Midline Actual Finding Slightly asymmetric Significance Due to swelling in the oral cavity Swelling, enlarged masses may indicate enlarged thyroid gland. Lumps or lesion may indicate trauma or cancer Tenderness may seen in with temporal arteritis May be pulled to one side in cases of a tumor, thyroid gland enlargement, aortic aneurism. Deviated landmark indicate masses or abnormal growth

Inspect the neck Palpation Palpate the head Palpate the temporal artery Palpate the trachea

Palpate for thyroid gland

Landmarks are positioned midline

EYE Assessment Procedure Inspection Eyelids and Eyelashes Normal Findings The upper lid margin should be bet the upper margin of the iris and upper margin of the pupil. Lower lid margin rest on the lower border of the iris. Bulbar conjunctiva is clear, moist and smooth. Sclera is white No swelling or redness should appear over areas of the lacrimal gland. Puncta is visible without swelling. The cornea is transparent, lens is free of opacities Actual Finding Significance Dropping of the upper lid may indicate ptosis.

Bulbar conjunctiva and Sclera Lacrimal apparatus

Tenderness suggests conjunctivitis. Swelling may be cause of blockage, inspection or inflammation around the puncta Dryness of the cornea associated with allergy. Opacities in lens may seen in cataracts Inequality of size is abnormal Sunken eyeballs Indicates dehydration.

Cornea and Lens

Iris and Pupil

Iris is round, flat and evenly colored. Pupil is round with a regular border. Equal in size, no redness

Eyeballs

EARS Assessment Procedure Inspection Inspect the auricle, tragus and lobule Normal Findings Ears are equal in size bilaterally. The auricle aligns with the corner of each eye. Lobes may be free, attached or soldered Small amount of odorless cerumen is the only discharge normally present Should be pearly, gray, shiny, and translucent with no bulging or retraction Not tender Actual Finding Significance Misaligned ears may be seen in GU disorders or chromosomal defects.

Inspect the external auditory canal Inspect eardrum

Abnormal findings may indicate infection Bulging may indicate otitis media

Palpation Palpate the auricle and mastoid process.

Pain may be associated with otitis externa Tenderness suggest mastoiditis and otitis media

MOUTH Assessment Procedure Inspection Inspect the lips Normal Findings Lips are smooth and moist without lesions or swelling. Actual Finding Significance

Inspect the teeth and gums

32 whitish teeth with smooth surfaces and edges Gums are pink, moist and firm with no lesions or masses. Should appear pink, smooth and moist without lesions Should be pink and moist Pale or whitish with firm rugae. Fleshy, solid structure that hangs freely in the midline. No redness. May be present or absent. Pink and symmetric. No exudates, swelling or lesions

Inspect for buccal mucosa Inspect the tongue Inspect hard and soft palate Assess the uvula

Inspect the tonsils

NOSE Assessment Procedure Inspection and Palpation I and P the external nose I the internal nose Normal Findings Color same as face, nasal structure is smooth and symmetric, no tenderness The nasal mucosa is dark pink, moist and free of exudate Actual Finding Significance Nasal tenderness suggest local infection Nasal mucosa is swollen or pale pink in clients with allergies.

SINUSES Assessment Procedure Palpation Palpate the sinuses Percussion Percuss the sinuses Normal Findings Non tender, no crepitus is evident Not tender upon percussion. Actual Finding Significance Tenderness may indicate allergy or acute rhino sinusitis. Tenderness suggest allergy or sinus infection Absence of red glow usually indicates a sinus filled with fluid or pus.

Transllumination Translluminate the sinus

Red glow translluminate the frontal sinuses. Indicates normal air filled sinus

THORACIC AND LUNGS

Assessment Procedure Inspection Inspect for nasal flaring and pursed lip breathing POSTERIOR THORAX Inspect configuration of the thorax Observe use of accessory muscles Palpation Palpate for tenderness Palpate for crepitus

Normal Findings Nasal flaring is not observed. Normally the diaphragm and the external intercostals muscles do most of the work of breathing. Scapulae are symmetric and non protruding. Shoulder and scapulae are at equal horizontal position. Do not use accessory muscle to assist breathing

Actual Finding

Significance Nasal flaring suggest hypoxia

Spinous process that deviate laterally indicate scoliosis Spinal configurations may have respiratory implications. Using accessory muscles to breathe Use of accessory muscles may indicate chronic airway obstruction or atelectasis Tenderness or pain may indicate inflamed fibrous connective tissues Crepitus may be palpated if air escapes from the lungs into subcutaneous tissue.

No tenderness, pain or unusual sensation. No palpable crepitus

Percussion Percuss for tone

Resonance is the percussion tone elicited over normal lung

Hyperresonance is elicited in cases of tapped air such as

tissue Auscultation Auscultate for breath sounds Normal breath sounds ( bronchial, bronchovesicular, vesicular) No adventitious breath sounds

emphysema or pneumothorax. Absent breath sounds indicate that little or no air is moving in or out the lung area being auscultated. Adventitious breath sounds may indicate respiratory problem

Auscultate for adventitious breath sounds

ANTERIOR THORAX Inspection Inspect for shape and configuration

The anteroposterior diameter is less than the transverse diameter. Midline and straight

Equal diameter result barrel chest which often seen in emphysema due to hyperinflation of the lungs. Sunken sternum suggest Pectus excavatum. Tenderness can result from exercising specially in previous sedentary client

Inspect position of the sternum Palpation Palpate for tenderness, sensation and surface masses.

No tenderness or pain

HEART AND NECK VESSEL

Assessment Procedure NECK VESSELS Inspection Observe the jugular venous pulse

Normal Findings Not normally visible with the client sitting upright.

Actual Finding

Significance Fully distended jugular veins with clients torso elevated more than 45 degrees indicate increased central venous pressure that may result to right ventricular failure.

Auscultation and Palpation Auscultate the carotid artery Palpate the carotid artery No blowing or swishing or other sounds heard. Pulse 0 1+ 2 + 3+ 4+ Amplitude Scale Absent Weak Normal Increased Bounding Sounds may indicate turbulent blood flow through narrowed vessel, indicate arterial disease Weak pulse may indicate hypovolemia, bounding may indicate hypervolemia.

HEART

Pulsation are considered

Inspection Inspect pulsation

May or may not be visible.

abnormal and should be evaluated. A heav or lift may occur as a result of an enlarged ventriclen from an overload of work. Impossible to palpate in clients with pulmonary emphysema. Larger apical impulse suggest cardiac enlargement. Bradycardia(less than 60bpm) or tachycardia ( more than 100bpm)may result to decrease cardiac output. Pathologic, pansystolic and diastolic murmurs may be a sign of heart problem.

Palpation Palpate the apical pulse

Palpated in the mitral area and may be a size of nickel (1-2cm)

Auscultation Auscultate heart rate and rhythm

Rate should be 60-100 bpm with regular rhythm.

Auscultate for murmurs

No murmurs are heard. Innocent and physiologic midsystolic murmurs may be present.

PERIPHERAL VASCULAR ASSESSMENT Assessment Procedure ARMS Inspection Observe arm size and venous pattern Observe coloration of hands and arms Normal Findings Symmetric with minimal variations in size and shape Color varies depending on the clients skin tone. Actual Finding Significance Lymphedema result from blocked lymphatic circulation Raynolds Disease, caused by vasoconstriction or vasospasm of fingers and toes, rapid change in color,swelling,pain, numbness and coldness. Capillary refill time exceeding 2 sec may indicate vasoconstriction Increased radial pulse indicate a hyperkinetic state.. Absent pulse suggest partial or complete arterial occlusion. With Fracture (Inserted with Steinman Pin) Ulcer(smooth margins) result from arterial insufficiency, Ulcer (irregular edges) result from venous insufficiency. Bilateral edema may be

Palpation Palpate for capillary refill Palpate for radial pulse

Capillary bed refill in 1-2 seconds or less Equal strength bilaterally (2+).

LEGS Inspection and Palpation Inspect for lesion or ulcers.

Free of lesion or ulceration

Inspect for edema

No swelling or atrophy

(+) Edema on lower extremeties Palpate edema No edema

detected by the absence of visible veins tendons and bony prominent. It usually indicates CHF, Renal Failure Pitting edema is associated with systemic problems such as CHF or hepatic cirrhosis or due to venous stasis due to insufficiency or prolonged sitting or sanding.Renal Failure

(+) Edema on lower extremeties

ABDOMEN

Assessment Procedure Inspection Coloration of the skin

Normal Findings Paler than the general skin color

Actual Finding

Significance Purple discoloration at the flanks indicates bleeding within the abdominal wall. Yellow hue of jaundice. Any bleeding moles or petechiae are abnormal

Assess lesions and rashes

Free of lesions and rashes, Flat or raised brown moles. Scaphoid abdomen

Assess for abdominal Abdomen is flat, rounded or scaphoid. contour

Due to decreased food intake

Auscultation Bowel sounds

A series of intermittent, soft clicks and gurgles are heard at a rate of 5-30 per min. Hyperactive bowel sounds may be heard normally.

Hypoactive bowel souns indicate diminish bowel motility.