CEPHALOCAUDAL ASSESSMENT

II. HEAD AND NECK

A. HEAD
GENERAL APPEARANCE Inspection:
a. Position ___________________________
a. Body built ___________________________________ b. Size and shape of the skull ___________________________
b. Posture and gait ___________________________________ c. Facial feature/edema ___________________________
c. Hygiene and appearance_________________________________ d. Symmetry of the eyelids ___________________________
d. Obvious signs of distress_________________________________ e. Symmetry of the eyebrows ___________________________
e. Obvious sign of illness or health f. Symmetry of the nasolabial folds______________________
g. Contour of the face ___________________________
MENTAL STATUS h. Involuntary movements ___________________________

a. Attitude ___________________________________ Palpation:

b. Affect and mood ___________________________________
c. Appropriateness of the client’s response ____________________ a. Masses/nodules/depressions_________________________
d. Speech pattern (quality, quantity, and organization) b. Lumps ___________________________
__________________________________________ c. Tenderness ___________________________
d. Deformities ___________________________
VITAL SIGNS e. TMJ (temporomandibular joint) _______________________

a. Temperature ___________________________________ B. FACIAL (CRANIAL NERVE VII)

b. Pulse rate ___________________________________  Ask the client to smile raise the eyebrow, frown, puff out,
c. Respiratory rate ___________________________________ cheeks, close eyes tightly
d. Blood pressure ___________________________________ _______________________________________________
e. Height ___________________________________  Ask client to identify various tastes placed on the tip and
f. Weight ___________________________________ sides of tongue.
_______________________________________________

I. INTEGUMENTARY SYSTEM C. VISUAL ACUITY

A. SKIN  Assess each pupil direct and consensual reaction to light
Inspection: _______________________________________________
a. Color and uniformity _______________________________  Assess each pupil’s reaction to accommodation to
b. Edema ___________________________________ convergence
c. Lesions ___________________________________ _______________________________________________
d. Pigmentation ___________________________________  Assess near vision ___________________________
e. Vascularity ___________________________________
 Assess distance vision ___________________________
Palpation:  Perform functional vision test _________________________
 Light perception ___________________________
a. Edema ___________________________________  Hand movement ___________________________
b. Moisture ___________________________________  Counting fingers ___________________________
c. Temperature ___________________________________
d. Texture ___________________________________ D. VISUAL FIELD
e. Turgor ___________________________________ Inspection:
f. Lesions/masses ___________________________________  Assess peripheral visual field
a. Conjunctiva and Sclera ___________________________
B. HAIR b. Cornea and lens ___________________________
Inspection: c. Eye alignment ___________________________
a. Color ___________________________________  Assess extraocular movements
b. Distribution ___________________________________ _________________________________________________
c. Quantity ___________________________________  Corneal light reflex test
d. Thickness ___________________________________ _________________________________________________
e. Texture ___________________________________  Cover-uncover test
f. Lubrication of body hair __________________________ _________________________________________________
g. Presence of lice/nits or parasites _________________
h. Dandruff ___________________________________ Palpation:

C. NAILS a. Edema ___________________________

Inspection:
a. Shape ___________________________________ b. Tenderness ___________________________
b. Angle color ___________________________________ c. Masses/lesions ___________________________
c. Texture ___________________________________ d. Nodules ___________________________
d. Thickness ___________________________________ e. Nasolacrimal duct and lacrimal sac_____________________
e. Cleanliness ___________________________________

Palpation: E. TRIGEMINAL (CRANIAL NERVE V)

 Ophthalmic branch
a. Capillary refill/blanch test __________________________  While client looks upward, lightly touch the lateral sclera of
the eye with sterile gauze to elicit blink reflex.
 ________________________________________________
 To test light sensation, have client close eyes, wipa a wisp of
cotton over cleint’s forehead and paranasal sinuses.
________________________________________________ b. Buccal mucosa
 To test deep sensation, use alternating blunt and sharp ends  Color ___________________________________
of safety pin over same areas.  Moisture ___________________________________
________________________________________________  Texture ___________________________________
 Presence or Lesions ________________________________
 Mandibular branch  Bleeding ___________________________________
 Ask the client to clench teeth.
________________________________________________ c. Teeth
 Number of teeth ___________________________________
 Color ___________________________________
III. EARS  Tooth alignment ___________________________________
Inspection  Loss of teeth ___________________________________
a. Auricles  Dental Fillings ___________________________________
 Color ___________________________________  Caries, Tartar, and dentures __________________________

 Symmetry and size ____________________________ d. Gums

 Position ___________________________________  Color ___________________________________
 Bleeding ___________________________________
b. External ear canal and tympanic membrane  Retraction ___________________________________
 Cerumen ___________________________________  Edema ___________________________________
 Skin lesions ___________________________________  Lesions ___________________________________
 Pus ___________________________________  Texture ___________________________________
 Blood ___________________________________
 Color ___________________________________ e. Tongue
 Position ___________________________________
Palpation:  Color ___________________________________
 Texture ___________________________________
a. Auricles  Movement ___________________________________
 Texture ___________________________________  Mouth floor ___________________________________
 Elasticity ___________________________________  Frenulum ___________________________________
 Tenderness __________________________________  Nodules, lumps, and excoriated area __________________

b. Hearing acuity f. Salivary glands

 Response to normal voice tones _________________  Swelling and redness _______________________________
 Whispered voice test __________________________
 Watch tick test _______________________________ g. Hard and Soft Palate
 Weber’s test _________________________________  Color ___________________________________
 Rinne’s test __________________________________  Shape ___________________________________
 Texture ___________________________________
c. Nose and Sinuses Inspection  Presence of bony prominences _______________________

EXTERNAL NOSE h. Uvula

 Position ___________________________________
 Deviation in shape and symmetry ________________  Mobility ___________________________________
 Size ___________________________________
 Color ___________________________________ i. Oropharynx
 Flaring ___________________________________  Color ___________________________________
 Discharges ___________________________________  Texture ___________________________________
NASAL CAVITIES
j. Tonsils
 Mucosa ___________________________________  Color ___________________________________
 Hairs ___________________________________  Discharge ___________________________________
 Redness ___________________________________  Size ___________________________________
 Swelling ___________________________________
k. Gag Reflex
 Growths ___________________________________
_________________________________________________
 Discharges ___________________________________
 Position of nasal septum ________________________
l. Glossopharyngeal (CRANIAL NERVE IX)
 Apply taste on posterior tongue for identification; ask client
IV. MOUTH
to move tongue from side to side and up and down
Inspection:
_________________________________________________
a. Lips ___________________________________
 Symmetry and contour______________________________
m. Hypoglossal (CRANIAL NERVE XII)
 Color ___________________________________
 Ask client to protrude tongue at midline, then move it side
 Texture ___________________________________
to side
 Tenderness ___________________________________
_________________________________________________
 d. Rate and rhythm for breathing _______________________
e. Use of accessory muscles ____________________________

V. NECK INSPECTION
Palpation
Inspection:
a. Lumps ___________________________________
a. Neck muscles ___________________________________ b. Masses ___________________________________
b. Head movement ___________________________________ c. Tenderness ___________________________________
c. Muscle strength ___________________________________ d. Unusual movement ________________________________
d. Thyroid gland ___________________________________ e. Tactile fremitus ___________________________________
f. Chest excursion ___________________________________
Palpation

a. Lymph nodes Percussion

 Tenderness ___________________________________
 Enlargement ___________________________________ a. Follow pattern of percussion
_________________________________________________
b. Trachea
 Deviation ___________________________________ Auscultation
 Alignment ___________________________________
a. Breath sounds ___________________________________
c. Thyroid Gland b. Adventitious sounds _______________________________
 Smoothness ___________________________________ c. Bronchophony ___________________________________
 Enlargement ___________________________________
 Masses ___________________________________
VII. HEART
 Nodules ___________________________________
Inspection And Palpation
 Symmetry ___________________________________
a. Visible pulsation ___________________________________
 Growths ___________________________________
b. Thrills ___________________________________
 Scars ___________________________________
c. Vibration ___________________________________
 Enlargement of parotid gland _____________________________
Auscultation

a. S1 ___________________________________
VI. THORAX AND LUNGS
b. S2 ___________________________________
c. S3 or ventricular gallop _____________________________
A. Posterior Thorax
d. S4 or atria gallop ___________________________________
Inspection
e. Clicks and rubs ___________________________________
a. Size and symmetry _________________________________
f. Murmurs ___________________________________
b. Shape ___________________________________
c. Deformities ___________________________________
VIII. BREAST
d. Position of the deviations ___________________________
Inspection
e. Slope of the ribs ___________________________________
a. Size and symmetry _________________________________
f. Retractions of the intercostals spaces __________________
b. Contour of the breast _______________________________
g. Rate and rhythm for breathing ________________________
c. Masses, flattening, retraction or dimpling, lesions
Palpation _________________________________________________
d. Color and venous pattern ____________________________
a. Lumps ___________________________________ e. Texture ___________________________________
b. Masses ___________________________________ f. Nipple size, color, shape, discharge and direction of nipple
c. Pulsations ___________________________________ point ____________________________________________
d. Unusual movement ________________________________
e. Chest excursion ___________________________________ Palpation
f. Tactile fremitus ___________________________________
a. Vertical strip ___________________________________
Percussion b. Circular ___________________________________
c. Wedge ___________________________________
a. Follow pattern on percussion
_________________________________________________

Auscultation

a. Breath sounds ___________________________________

b. Adventitious sounds ________________________________ IX. ABDOMEN
c. Bronchophony ____________________________________ Inspection
a. Skin (striae, scars, bruises) ___________________________
B. Anterior Thorax b. Umbilicus (position, color, signs of inflammation, discharge,
Inspection protruding masses) ________________________________
a. Symmetry ___________________________________ c. Contour and symmetry ______________________________
b. Shape and size ___________________________________ d. Enlarged organs and masses __________________________
c. Deformities ___________________________________
 Auscultation a. Gross motor and Balance Test
 Walking gait ___________________________________
a. Bowel motility ___________________________________  Romberg’s test ___________________________________
b. Vascular sounds ___________________________________  Standing on the foot with eye closed _______________________
 Heel-toe walking ___________________________________
Percussion
b. Fine motor test for upper extremities
a. Organs and masses ________________________________  Finger to nose test ___________________________________
b. Liver size ___________________________________  Alternating supination and pronation of hands on knees
c. Kidney tenderness/kidney punch _____________________ _____________________________________________________
 Finger to nose and to nurse’s fingers
Palpation _____________________________________________________
 Finger to fingers ___________________________________
a. Tenderness ___________________________________  Finger to thumb ___________________________________
b. Distension ___________________________________
c. Masses ___________________________________ c. Fine motor test for lower extremities
d. Muscular resistance ________________________________  Heel down opposite shin
e. Rebound tenderness _______________________________ ______________________________________________________
f. Liver size ___________________________________  Toe or ball of foot to the nurse’s fingers
______________________________________________________

X. MUSCULOSKELETAL SYSTEM

Inspection

a. Range of motion____________________________________
b. Muscle strength and tone ____________________________
c. Joint and muscles condition __________________________
d. Gait ___________________________________
e. Posture ___________________________________
f. Gross deformities___________________________________
g. Bony enlargement __________________________________
h. Alignment ___________________________________
i. Symmetry and Size _________________________________
j. Contractures ___________________________________
k. Fasciculation and Tremors ___________________________

Palpation

a. Heat ___________________________________
b. Tenderness ___________________________________
c. Edema ___________________________________
d. Resistance of motion ________________________________
e. Muscle Tone and Strength ___________________________

XI. NEUROLOGICAL SYSTEM

A. MENTAL AND EMOTIONAL STATUS

a. Level of consciousness ______________________________
b. Behavior and appearance ____________________________
c. Language ___________________________________
d. Orientation ___________________________________
e. Attention span and calculation ________________________

B. INTELLECTUAL NERVE FUNCTION

a. Memory ___________________________________
b. Knowledge ___________________________________
c. Abstract thinking___________________________________
d. Association ___________________________________
e. Judgment ___________________________________

C. SENSORY NERVE FUNCTION

a. Pain ___________________________________
b. Temperature ___________________________________
c. Light touch ___________________________________
d. Vibration ___________________________________
e. Position ___________________________________
f. Two-point discrimination ____________________________

D. MOTOR FUNCTIONS