Integration of the Physical Assessment

1
Integration of the Physical Assessment

• Putting it all together
• Dr. Sara Mitchell
• November 3, 2006

2
At the very beginning

• Introduce yourself and explain what you are about
  to do
• Take the client's history
• Take measurements
• vital signs/ height weight

3
Helpful Hints

• Be prepared
• gather supplies equipment before starting
  examination
• test all equipment to make sure it is in working
  order
• Be organized and systematic in your approach
• use the fewest number of client position changes

4
Preparation for examination

• Equipment needed
• Client and environment readiness

5
Techniques for examination

• Inspect general appearance
• skin color
• consistency of general appearance with age
• general state of nutrition
• hygiene
• obvious physical deformities, limitations, use of
  assistive devices

6
Techniques for examination

• Inspect stature and movement
• symmetry
• posture
• body build
• mobility

7
Techniques for examination

• Inspect demeanor
• facial expression
• composure
• speech
• orientation and mental status
• disposition
• eye contact

8
With the client sitting and the examiner facing
the client examine the following systems

• Upper extremities
• HEENT including face neck
• Cranial nerves

• Spine
• Lungs (anterior, posterior, lateral)
• Heart
• Breast

9
Have the client lie in a supine position with the
examiner at the clients right side examine the
following

• Breasts
• Heart
• Abdomen
• Lower extremities

10
Have the client resume a sitting position with
the examiner standing in front of the client and
assess the following

• Neural system
• deep tendon reflexes (DTRs)
• cerebellar function
• sensory function
• two-point discrimination
• stereognosis, graphesthia
• position sense

11
With the client still seated complete the
following

• Assessment of upper extremities
• strength
• range of motion
• sensation
• vibration
• position sense

12
With the client in the standing position assess
the following

• Examination of spine and sacral area
• The remainder of the neural system evaluation
• inspect gait
• assess proprioception and cerebellar function

13
Genitalia Examination

• For the male client the following are assessed
  with the client in a standing position
• external genitalia
• presence of hernia
• rectal exam
• For the female client the exam is done with the
  client in the lithotomy position

14
Documentation

• Be specific
• Be concise
• Be complete
• Avoid using vague terms, such as negative,
  normal, or good
• Be truthful
• only record your actual findings
• specify portion of the examination that were
  omitted or deferred