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III.

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

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

Uniform color; flat


rounded (convex), or
scapoid (concave)
contour; symmetric
contour; audible
bowel sounds;
absence of arterial
bruits; absence of
friction rub

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

Pubic 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

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

IV. SYSTEM APPROACH


Integu
men
tary

Normal Findings

Initial
Assessment

Latest Assessment

Consist 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
temperature
P: No
abnormalities
noted
A: Not applicable

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.
P: No masses and
tenderness noted,
normal skin temperature
P: No abnormalities
noted
A: Not applicable

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

The 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 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

The 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
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

The 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 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

The 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
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.

I: The client has


normal voiding
pattern.
P: not noted
P: Not noted
A: Not noted

I: The client has


normal voiding
pattern.
P: Not noted
P: not noted
A: Not noted