1. PHYSICAL EXAMINATION

2. Midterm Systems Midterm Systems requirements assessment -critical elements-used on care plan -critical elements-used on care plan -includes systems -used in hosp.

3. CRITICAL ELEMENTS Wash hands and gather equipment Wash hands and gather equipment Prepare assessment area Prepare assessment area Introduce yourself and state purpose Introduce yourself and state purpose Observe general appearance Observe general appearance Measure height and weight Measure height and weight

4. NEUROLOGICAL SYSTEM LOC LOC Orientation Orientation PERRLA PERRLA (Pupils Equal Round Reactive to Light and Accommodation) (Pupils Equal Round Reactive to Light and Accommodation) Sensation (light touch/temperature) Sensation (light touch/temperature)

5. Light touch

6. CARDIOVASCULAR SYSTEM

7. Listen at Listen at 4 sites Take Take apical pulse (note rhythm /murmur) S1, S2 S1, S2

8. Assess pulses Assess pulses

9. Assess for edema Assess for Homan’s sign

10. Nailbeds Color Color Cap refill Cap refill(UE/LE)

12. RESPIRATORY SYSTEM Assess rate/depth rhythm Assess rate/depth rhythm Assess lung sounds Assess lung sounds 10 sites anterior/ 9 sites posterior 10 sites anterior/ 9 sites posterior

13. Anterior sites

14. Posterior sites

15. GASTROINTESTINAL SYSTEM Abd contour Abd contour

17. Bowel sounds Bowel sounds Masses Masses Bowel Bowelmovement

18. Genitourinary System Bladder distention Bladder distention

19. Musculoskeletal System Gait Gait Bilateral hand grip Bilateral hand grip Bilateral hand strength Bilateral hand strength ROM (UE and LE) ROM (UE and LE)

20. Integumentary System Color Color Texture Texture Turgor Turgor Temperature Temperature Moisture Moisture Abnormalities Abnormalities