Integration of the Physical Assessment Putting it all together Dr. Sara Mitchell November 3, 2006

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

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

Preparation for examination Equipment needed Client and environment readiness

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

Techniques for examination Inspect stature and movement symmetry posture body build mobility

Techniques for examination Inspect demeanor facial expression composure speech orientation and mental status disposition eye contact

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

Have the client lie in a supine position with the examiner at the client’s right side examine the following: Breasts Heart Abdomen Lower extremities

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 (DTR’s) cerebellar function sensory function two-point discrimination stereognosis, graphesthia position sense

With the client still seated complete the following Assessment of upper extremities strength range of motion sensation vibration position sense

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

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

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