COLEGIO SAN AGUSTIN BACOLOD

COLLEGE OF HEALTH AND ALLIED PROFESSIONS

NURSING PROGRAM
B.S. Aquino Drive, Bacolod City
Contact Number: (034) 434 – 24 71 Local 162
Email Address: [email protected]

FORMAT OF CEPHALOCAUDAL PHYSICAL ASSESSMENT

DATE BODY PART/S BOOK VIEW OBSERVATION

Skull, Scalp & Hair Skull I- inspection
• Observe the size, shape, and • Generally round, with p- palpation
contour of the skull. prominences in the frontal P- percussion
• Observe scalp in several areas by and occipital area. A - auscultation
separating the hair at various (Normocephalic).
locations; inquire about any • No tenderness noted upon
injuries. Note presence of lice, nits, palpation.
dandruff or lesions.
• Palpate the head by running the Scalp
pads of the fingers over the entire • Lighter in color than the
surface of the skull; inquire about complexion.
tenderness upon doing so. (wear • Can be moist or oily.
gloves if necessary) • No scars noted.
• Observe and feel the hair condition. • Free from lice, nits, and
dandruff.
• No lesions should be
noted.
• No tenderness or masses
on palpation.

Hair
• Can be black, brown or
burgundy depending on
the race.
• Evenly distributed covers
the whole scalp
• No evidence of Alopecia
• Maybe thick or thin,
coarse or smooth.
• Neither brittle nor dry.

Face
• Observe the face for
shape.
• Inspect for Symmetry.
o Inspect for the
palpebral fissure (distance
between the eyelids);
should be equal in both
eyes.
o Ask the patient to
smile, There should be
bilateral Nasolabial fold
(creases extending from the
angle of the corner of the
mouth). Slight asymmetry
in the fold is norm If both
are met, then the Face is
symmetrical.

Eyebrows, Eyes, and Eyelashes Eyebrows

• All three structures are assessed • Symmetrical and in line
using the modality of inspection. with each other.
 • Maybe black, brown or
blond depending on race.
• Evenly distributed

Eyes

• Evenly placed and inline

with each other.
• None protruding.
• Equal palpebral fissure.

Eyelashes

• Color dependent on race.

• Evenly distributed.
• Turned outward.

Sclerae • Sclerae is white in color

• The sclerae are easily inspected (anicteric sclera)
during the assessment of the • No yellowish discoloration
conjunctivae. (icteric sclera).
• Some capillaries may be
visible.
• Some people may have
pigmented positions.

Cornea • There should be no

• The cornea is best inspected by irregularities on the
directing penlight obliquely from surface.
several positions. • Looks smooth.
• The cornea is clear or
transparent. The features
of the iris should be fully
visible through the cornea.
• There is a positive corneal
reflex.

Ears • The earlobes are bean-

• Inspect the auricles of the ears for shaped, parallel, and
parallelism, size position, symmetrical.
appearance and skin color. • The upper connection of
• Palpate the auricles and the the ear lobe is parallel
mastoid process for firmness of the with the outer canthus of
cartilage of the auricles, tenderness the eye.
when manipulating the auricles and • Skin is the same in color as
the mastoid process. in the complexion.
• Inspect the auditory meatus or the • No lesions noted on
ear canal for color, presence of inspection.
cerumen, discharges, and foreign • The auricles have firm
bodies. cartilage on palpation.
• For adult pull the pinna upward and • The pinna recoils when
backward to straighten the canal. folded.
• For children pull the pinna • There is no pain or
downward and backward to tenderness on the
straighten the canal palpation of the auricles
• Perform otoscopic examination of and mastoid process.
the tympanic membrane, noting • The ear canal has normally
the color and landmarks. some cerumen of
inspection.
 • No discharges or lesions
noted at the ear canal.
• On otoscopic examination,
the tympanic membrane
appears flat, translucent
and pearly gray in color.

Nose and Paranasal Sinuses • Nose in the midline

• The external portion of the nose is • No Discharges.
inspected for the following: • No flaring alae nasi.
o Placement and symmetry. • Both nares are patent.
o Patency of nares (done by • No bone and cartilage
occluding nostril one at a deviation noted on
time, and noting for palpation.
difficulty in breathing) • No tenderness noted on
o Flaring of alae nasi palpation.
o Discharge • Nasal septum in the
midline and not
• The external nares are palpated for: perforated.
o Displacement of bone and • The nasal mucosa is
cartilage. pinkish to red in color.
o For tenderness and masses (Increased redness
o The internal nares are turbinates are typical of
inspected by allergy).
hyperextending the neck of • No tenderness noted on
the client, the ulnar aspect palpation of the paranasal
of the examiners hard over sinuses.
the forehead of the client,
and using the thumb to
push the tip of the nose
upward while shining a
light into the nares.

• Inspect for the following:

o Position of the septum.
o Check septum for
perforation. (Can also be
checked by directing the
lighted penlight on the side
of the nose, illumination at
the other side suggests
perforation).
o The nasal mucosa
(turbinates) for swelling,
exudates, and change in
color.

Paranasal Sinuses
• Examination of the paranasal
sinuses is indirect. Information
about their condition is gained by
inspection and palpation of the
overlying tissues. Only frontal and
maxillary sinuses are accessible for
examination.
• By palpating both cheeks
simultaneously, one can determine
tenderness of the maxillary
sinusitis, and pressing the thumb
just below the eyebrows, we can
determine tenderness of the
frontal sinuses.

Gums • Pinkish in color

Inspected for: • No gum bleeding
• Color • No receding gums
• Bleeding
• Retraction of gums.

Teeth • 28 for children and 32 for

Inspected for: adults.
• Number • White to yellowish in color
• Color • With or without dental
• Dental caries caries and/or dental
• Dental fillings fillings.
• Alignment and malocclusions (2 • With or without
teeth in the space for 1, or malocclusions.
overlapping teeth). • No halitosis.
• Tooth loss
• Breath should also be assessed
during the process.

Tongue • Pinkish with white taste

Palpated for: buds on the surface.
• Texture • No lesions noted.
• No varicosities on ventral
surface.
• Frenulum is thin attaches
to the posterior 1/3 of the
ventral aspect of the
tongue.
• Gag reflex is present.
• Able to move the tongue
freely and with strength.
• Surface of the tongue is
rough.

Uvula • Positioned in the midline.

Inspected for: • Pinkish to red in color.
• Position • No swelling or lesion
• Color noted.
• Cranial Nerve X (Vagus nerve) – • Moves upward and
Tested by asking the client to say backward when asked to
“Ah” note that the uvula will move say “ah”
upward and forward.
Neck

• The neck is inspected for position • The neck is straight.

symmetry and obvious lumps • No visible mass or
visibility of the thyroid gland and lumps.
Jugular Venous Distension • Symmetrical
• Check the Range of Movement of • No jugular venous
the neck. distension (suggestive of
cardiac congestion).
• The neck is palpated just
above the suprasternal
note using the thumb and
the index finger.
• The trachea is palpable.
• It is positioned in the line
and straight.
• Lymph nodes are
palpated using palmar
tips of the fingers via
systemic circular
movements. Describe
lymph nodes in terms of
 size, regularity,
consistency, tenderness,
and fixation to
surrounding May not be
palpable. Maybe
normally palpable in thin
clients.
• Non-tender if palpable.
• Firm with smooth
rounded surface.
• Slightly movable.
• About less than 1 cm in
size.
• The thyroid is initially
observed by standing in
front of the client and
asking the client to
swallow. Palpation of the
thyroid can be done
either by posterior or
anterior approach.
• tissues.

Breast
Inspection of the Breast • The overlying the breast
• There are 4 major sitting position of should be even.
the client used for clinical breast • May or may not be
examination. Every client should be completely symmetrical at
examined in each position. rest.
o The client is seated with • The areola is rounded or
her arms on her side. oval, with same color,
o The client is seated with (Color varies from light
her arms abducted over the pink to dark brown
head. depending on race).
o The client is seated and is • Nipples are rounded,
pushing her hands into her everted, same size and
hips, simultaneously equal in color.
eliciting contraction of the • No “orange peel” skin is
pectoral muscles. noted which is present in
o The client is seated and is edema.
learning over while the • The veins may be visible
examiner assists in but not engorge and
supporting and balancing prominent.
her. • No obvious mass noted.
• While the client is performing these • Not fixated and moves
maneuvers, the breasts are bilaterally when hands are
carefully observed for symmetry, abducted over the head,
bulging, retraction, and fixation. or is leaning forward.
• An abnormality may not be • No retractions or dimpling.
apparent in the breasts at rest a
mass may cause the breasts,
through invasion of the suspensory
ligaments, to fix, preventing them
from upward movement in position
2 and 4.
• Position 3 specifically assists in
eliciting dimpling if a mass has
infiltrated and shortened
suspensory ligaments.

Palpation of the Breast

 • Palpate the breast along imaginary
concentric circles, following a
clockwise rotary motion, from the
periphery to the center going to the
nipples. Be sure that the breast is
adequately surveyed. Breast
examination is best done 1-week
post menses. • No lumps or masses are
• Each areolar areas are carefully palpable.
palpated to determine the presence • No tenderness upon
of underlying masses. palpation.
• Each nipple is gently compressed to • No discharges from the
assess for the presence of masses or nipples.
discharge. • NOTE: The male breasts
are observed by adapting
the techniques used for
female clients. However,
the various sitting position
used for woman is
unnecessary.

Abdomen • Skin color is uniform, no

• In abdominal assessment, be sure lesions.
that the client has emptied the • Some clients may have
bladder for comfort. Place the striae or scar.
client in a supine position with the • No venous engorgement.
knees slightly flexed to relax • Contour may be flat,
abdominal muscles. rounded or scaphoid
• Thin clients may have
Inspection of the abdomen visible peristalsis.
• Inspect for skin integrity • Aortic pulsation may be
(Pigmentation, lesions, striae, scars, visible on thin clients.
veins, and umbilicus).
• Contour (flat, rounded, scaphoid)
• Distension
• Respiratory movement.
• Visible peristalsis.
• Pulsations

Auscultation of the Abdomen

• This method precedes percussion
because bowel motility, and thus
bowel sounds, may be increased by
palpation or percussion.
• The stethoscope and the hands
should be warmed; if they are cold,
they may initiate contraction of the
abdominal muscles.
• Light pressure on the stethoscope
is sufficient to detect bowel sounds
and bruits. Intestinal sounds are
relatively high-pitched, the bell may
be used in exploring arterial
murmurs and venous hum.

Peristaltic sounds
• These sounds are produced by the
movements of air and fluids
through the gastrointestinal tract.
Peristalsis can provide diagnostic
clues relevant to the motility of
bowel.
 • Listening to the bowel sounds
(borborygmi) can be facilitated by
following these steps:
o Divide the abdomen into
four quadrants.
o Listen over all auscultation
sites, starting at the right
lower quadrants, following
the cross pattern of the
imaginary lines in creating
the abdominal quadrants.
This direction ensures that
we follow the direction of
bowel movement.
o Peristaltic sounds are quite
irregular. Thus it is
recommended that the
examiner listen for at least
5 minutes, especially at the
periumbilical area, before
concluding that no bowel
sounds are present.
o The normal bowel sounds
are high-pitched, gurgling
noises that occur
approximately every 5 – 15
seconds. It is suggested
that the number of bowel
sound may be as low as 3
to as high as 20 per minute,
or roughly, one bowel
sound for each breath
sound.
o Some factors that affect
bowel sound:
▪ Presence of food in
the GI tract.
▪ State of digestion.
▪ Pathologic
conditions of the
bowel
(inflammation,
Gangrene, paralytic
ileus, peritonitis).
▪ Bowel surgery
▪ Constipation or
Diarrhea.
▪ Electrolyte
imbalances.
▪ Bowel obstruction.

Percussion of the abdomen

• Abdominal percussion is aimed at
detecting fluid in the peritoneum
(ascites), gaseous distension, and
masses, and in assessing solid
structures within the abdomen.
• The direction of abdominal
percussion follows the auscultation
site at each abdominal guardant.
• The entire abdomen should be
percussed lightly or a general
picture of the areas of tympany and
dullness.
 • Tympany will predominate because
of the presence of gas in the small
and large bowel. Solid masses will
percuss as dull, such as liver in the
RUQ, spleen at the 6th or 9th rib
just posterior to or at the
midaxillary line on the left side.
• Percussion in the abdomen can also
be used in assessing the liver span
and size of the spleen.

Palpation of the Abdomen • No tenderness noted.

Light palpation • With smooth and
consistent tension.
• It is a gentle exploration performed • No muscles guarding.
while the client is in supine position. Deep Palpation
With the examiner’s hands parallel • It is the indentation of the
to the floor. abdomen performed by
• The fingers depress the abdominal pressing the distal half of
wall, at each quadrant, by the palmar surfaces of the
approximately 1 cm without digging, fingers into the abdominal
but gently palpating with slow wall.
circular motion. • The abdominal wall may
• This method is used for eliciting slide back and forth while
slight tenderness, large masses, and the fingers move back and
muscles, and muscle guarding. forth over the organ being
• Tensing of abdominal musculature examined.
may occur because of: • Deeper structures, like the
o The examiner’s hands are liver, and retroperitoneal
too cold or are pressed to organs, like the kidneys, or
vigorously or deep into the masses may be felt with
abdomen. this method.
o The client is ticklish or • In the absence of disease,
guards involuntarily. pressure produced by
o Presence of subjacent deep palpation may
pathologic condition. produce tenderness over
the cecum, the sigmoid
colon, and the aorta.

Extremities • Both extremities are equal

in size.
Inspection • Have the same contour
• Observe for size, contour, bilateral with prominences of
symmetry, and involuntary joints.
movement. • No involuntary
• Look for gross deformities, edema, movements.
presence of trauma such as • No edema
ecchymosis or other discoloration. • Color is even.
• Always compare both extremities. • Temperature is warm and
even.
Palpation • Has equal contraction and
• Feel for evenness of temperature. even.
Normally it should be even for all • Can perform complete
the extremities. range of motion.
• Tonicity of muscle. (Can be • No crepitus must be noted
measured by asking client to on joints.
squeeze examiner’s fingers and • Can counteract gravity and
noting for equality of contraction). resistance on ROM.
• Perform range of motion.
• Test for muscle strength.
(performed against gravity and
against resistance)
 • Table showing the Lovett scale for
grading for muscle strength and
functional level

PREPARED BY:

MARY LOU GONZAGA ABRAHAM, RN, MAN

CLINICAL AND CHN COORDINATOR

ENDORSED BY:

REYMA MIJARES MAGBANUA, RN, MAN

PROGRAM HEAD AND RESEARCH COORDINATOR

APPROVED BY:

DR. JO ANN ALIBOSO FLORES, RN

DEAN