CEPHALOCAUDAL ASSESSEMENT

BODY PARTS ASSESSMENT

1. SKIN  The skin is brown, wrinkled skin

 The temperature of skin is normal,
the patient’s skin is a little dry and
rough. There is no presence of
lesions, bruise, rashes or tattoos. No
complain of bleeding.

2.HAIR  The hair color of the patient is almost

all white, short and straight, there is
no presence of any dandruff or lice.
There is no presence of hair in axilla
and leg part.

 The patient has a light brown nails

3. NAILS and has the shape of convex curve
 Fingernails are short in length.

4. HEAD  The head of the client is round and

symmetrical. No lumps and it is hard.
5. SKULL  There are no nodules or masses and
depressions when palpated.

  The face of the patient appeared

6. FACE wrinkled and dryly smooth and has
uniform consistency and with no
presence of nodules or masses.

7. EYES and VISION

 EYEBROWS  The client’s hair is evenly distributed.

The client’s eyebrows are
symmetrically aligned and showed
equal movement when asked to raise
and lower eyebrows.
  EYELASHES  Eyelashes appeared to be equally
distributed and it is short and slightly
outward.

 EYELIDS  There was no presence of discharges,

no discoloration and lids close
symmetrically 

 EYES  The sclera of the patient appeared

white

 There is no edema or tearing of the

lacrimal gland. The client blinks when
the cornea was touched. The pupils of
the eyes are black and equal in size.
The iris is flat and round.

 The patient is having a hard time

reading

8. EARS AND HEARING  The Auricles are symmetrical and has the
same color with his facial skin. The
auricles are aligned with the outer
canthus of eye.  It is clean. No foul smell,
no abnormal deformities. No
enlargement of other parts of the ear.
The patient can’t hear clearly.

9. NOSE AND SINUS  The nose appeared symmetric,

straight and uniform in color. There
was no presence of discharge or
flaring. When lightly palpated, there
were no tenderness and lesions

10. MOUTH  The lips of the patient are lightly dark,

it is equal in size. It is a bit dry but
there were no lesions or mouth sores
were seen. Gums
11. TEETH AND GUMS  The tongue of the client is centrally
positioned. It is pink in color, moist
and slightly rough.
 There are no discoloration of the
enamels, no retraction of gums
12. NECK  The neck muscles are equal in size.
The client showed coordinated,
smooth head movement with no
discomfort.

13. CHEST AND LUNGS   The chest wall is intact with no

tenderness and masses.

 The spine is vertically aligned. The

right and left shoulders and hips are
of the same height.

NURSE PATIENT COMMUNICATION ANALYSIS

TECHNIQUE
 Magandang  Ay wenla  Giving  To start
umaga po, ako nakkong. information rapport
po si Janelle
Supnad,
student nurse
po from UNP.
20 years old po

 Lola kayo po ba  Wen nakkong  Giving  To start

si Remedios recognition trust
Sabaten?

 Malapit lang po  Wen nakkong,  Broad

ba kayo dito? taga cabugao openings  To obtain
kami met lang, information
asideg kami lang
ditoy.

 Babantayan ko  Sige nakkong,  Giving

po kayo sa thank you ah information  To start
lunes at martes rapport
ng umaga po,
sabihan niyo po
ako pag may
masakit po o
pag may
kailangan po
kayo.

 Kapatid niyo po  Ay wen nakkong,  Exploring

ba ang suda nga dwa
nagbabantay sa kabsat ko,  To obtain
inyo? kabbalay ko di information
mesa, tapos
karruba mi met
lang toy mesa