V.

PHYSICAL ASSESSMENT ( CEPHALO CAUDAL)

a. General Survey
b. Measurements (Height, Weight, BMI, Vital signs)

Assessment Body Part Normal Findings Actual Findings Analysis &

(Cephalo- Interpretation
Method Used
caudal) (with reference)

Head Head is free from  The head of the

lesions and no signs child is free
Inspection And of deformities such from lesions
Palpation as brachycephaly with Normal
scaphocephaly etc.  Size of 72.8 cm
Ears and no signs of Retrieved from:
Ears
deformities
2017 Dept. of
The top of the pinna such as
Pediatrics University
should cross the eye brachycephaly,
of Texas Medical
occiput line and be scaphocephal
Branch
y etc.
within a 10 degree
angle of
perpendicular line
drawn from the eye
occiput line to the Normal
 The ears of the
lobe.
client has no Retrieved from:
No Unusual markings lesions
or structures in the  No 2019 Stanford
pinna. misalignment Medicine
within greater
No excessive than 10 degree
cerumen, discharge, angle.
lesions, excoriations,  No preauricular
or foreign body in skin tags and
external canal. unusual
Tympanic Membrane structure or
should be pearly markings in the
gray to light pink and pinna.
mobile.  Tympanic
Membrane is
Tympanic can be light pink and
redden bilateral if mobile.
 The infant
exhibits signs of
 the child is crying or being startled
febrile. or also called
the Moro
The infant shows reflex.
Moro reflex

Neck  No bulging
Neck
masses
is free from bulging palpated with Normal
masses , with a full  observed full
Retrieved from :
range of motion and range of
no bony motion 2014 by the
abnormalities should observed American Academy
be seen in the  No of Family Physicians.
cervical spine. abnormalities
seen in the
bone structure.

Inspection Eyes Inner Canthus Normal:

distance
approximately 2.5  No foreign Retrieved from:
cm, horizontal slant, bodies are
Weber J. Kelley J.
no epicanthal folds. seen
(sixth edition)
Outer canthus aligns  Sclera and
Health Assessment
with tips of the conjunctiva is
in Nursing
pinna. clear
 Free from
Sclera and discharge,
conjunctiva is clear lesions ,
with no discharge, redness or
lesions, Redness and lacerations
lacerations.  Eyebrows are
symmetrical
Eyelids have
and does not
transient edema,
meet in the
absence of tears
midline.
Eyebrows should not
meet in the midline
 and eyelashes should
be evenly distributed

Inspection Mouth Lips are smooth and  Lips are pink Normal
moist without with no lesions
lesions and swelling. Weber J. Kelley J.
observed
(sixth edition)
 No breath odor
Gums are Pinkish Health Assessment
 Gums are
with no lesions or in Nursing
pinkish with no
masses buccal
masses , Buccal
mucosa, Pharyngeal
mucosa are
wall and tongue
also color pink
should be also
without lesions
pinkish without
 Tongue are
lesions.
pink but
slightly whitish
because of the
milk
 Pharyngeal
wall is smooth
and pinkish
without
lesions.

Inspection Nose  Nose is seen in Normal Retrieved

the midline from:https://www.s
Nose seen in the lideshare.net/moniq
with no lesions.
midline of the face,
 Septum is uetrejeros7/infant-
septum is straight, physical-assessment
intact with no
and nares are patent
lesions and
No discharge are
ulcerations.
present.
 No bulging
The Patency of the masses inside
Airflow should be the nose
normal.  Exhibits a
normal Patency
airflow
 Thorax of an infant  No retraction Normal Retrieved
should be smooth has been from:https://www.s
Inspection and Thorax rounded and lideshare.net/moniq
observed
Auscultation symmetrical  No lesions uetrejeros7/infant-
 Smooth, physical-assessment
Exhibit louder and
Rounded and
harsh breath sounds
symmetrical
due to the thin chest
 The respiration
walls
of the child is
The respiration of unlabored
the child should not  No
be unlabored and adventitious
there should not and stridor
have adventitious sounds has
sound can be heard been heard
over the thorax.  Exhibits a
louder pitch of
breath sounds
with no
wheeze and
crackles.

Inspection and Skin, Skin color has a  The skin color Normal
Palpation Nails and evenly skin tones is brown
Hair without unusual or  The skin is
prominent uniform
discoloration:  No
discoloration
Skin is intact and
has been
there are no
observed
reddened area
 Minimal insect
No lesions should be bites are
palpated present in the
right and left
No edema should be part of her legs
seen and it may  No foul odor in
exhibit odor but it the skin
 should depends on  No edema has
the client activity been observed
 The skin of the
Freckles, some birth
infant is warm
marks, some flat and
to touch
raised nevi can be
 Nails are
present.
pinkish and
intact
 The scalp is
clean and dry
and the hair is
smooth and
silky with an
evenly amount
distribution of
hair.

Inspection and Abdomen In infants the  The infant’s Normal

Palpation abdomen is abdomen color
prominent in supine is light brown
position. with no
discoloration.
Abdomen is free
 No rashes and
from lesions and
lesions
rashes umbilical skin
observed
tones is similar with
 The Abdominal
the surrounding
contour is
abdominal skin tones
rounded
or even pinkish,
Umbilicus is at the
 midline at a lateral  There is no
position and the bulging masses
abdominal contour is palpated
rounded and not  The umbilicus
distended nor is intact and
scaphoid. seen in the
midline
Abdominal
 The client
respiratory
exhibits
movement is present
respiration in
No bulging masses her abdomen.
should be palpated in  The liver is
the abdominal area. palpable
within 1-2 cm
Liver Should be
palpable 1-2 cm
below the right
costal margin in
young children

Inspection Musculoskeletal Arms, Hands, Feet  No deformities Normal

and Legs are and swelling
symmetrical has been
bilaterally . observed in
Extremities is warm the client
and mobile with an  The
adequate capillary extremities of
refill. the infant is
warm to touch
Muscles should be
 The infant
equal bilateral in
shows a full
sizes and no
range of
deformities should
motion with
be seen.
no tenderness.
Full range of motion
is present with no
swelling in the
Musculoskeletal