1. PHYSICAL ASSESSMENT-
SYSTEMATIC EXAMINATION
OF BODY STRUCTURES
IDENTIFY THE CLIENT/ REVIEW CLIENT’S MEDICAL HISTORY
DETERMINE THE CLIENT’S AGE, GENDER, AND RACE
OBSERVE THE CLIENT’S STATE OF ALERTNESS AND ABILITY TO MOVE;
physical appearance in relation to their clothing and hygiene
ASK A CLIENT’S OPINION ABOUT HIS OR HER HEALTH STATUS AND
ANY CURRENT OR RECENT SIGNS AND SYMPTOMS
WASH HANDS IN FRONT OF CLIENT
EXPLAIN PROCEDURE TO CLIENT
ANSWER CLIENT’S QUESTIONS
DR. JAMES M. ALO, RN, MAN,MAP, PHD
2. PHYSICAL ASSESSMENT/
ENVIRONMENT
l ORGANIZE EQUIPMENT
l Easy access to a restroom-
empty bladder
l ASSIST CLIENT TO A SITTING
POSITION, IF APPLICABLE ON A
PADDED, ADJUSTABLE TABLE
OR BED
l SUFFICIENT ROOM FOR
MOVING TO EITHER SIDE OF
THE CLIENT
l WELL-LIT, WARM, PRIVATE
ROOM-PULL CURTAIN
l FACILITIY TO WASH HANDS
l CLEAN COUNTER FOR
PLACING EQUIPMENT
l A LINED RECEPTACLE FOR
SOILED ARTICLES
drjAlol EXAMINE CLIENT 2
l HEIGHT, WEIGHT
4. “PURPOSES-gather objective data from
client”
l OBTAIN BASELINE MEASUREMENTS/FOR FUTURE
COMPARISONS
l COMPARE WITH NORMAL DATA (VARY WITH AGE-
NORMAL TEMPERATURE DO NOT RULE OUT
ILLNESS, ESP. YOUNG OR ELDERLY
l EVALUATE CLIENT’S CURRENT PHYSICAL
CONDITION
l DETECT EARLY SIGNS OF DEVELOPING HEALTH
PROBLEMS
l TO EVALUATE THE CLIENT’S RESPONSES TO
MEDICAL AND NURSING INTERVENTIONS
drjAlo 4
5. VITAL SIGNS
l BODY
TEMPERATURE
l PULSE RATE
l RESPIRATORY
RATE
l BLOOD PRESSURE
drjAlo 5
6. VITAL SIGNS-NORMAL RANGES
l TEMP-98.6-100.4 (ORAL)
l 100.4-100.8 (RECTAL)
l 95.8-99.4 (AXILLARY)
l TYMPANIC-CALIBRATED TO ORAL OR RECTAL
SCORE
l PULSE-60-100 BEATS/MIN(NORMAL,WEAK,
REGULAR, IRREGULAR, C/O OF PALPITATIONS)
l RESPIRATIONS-MEN=14-18/MIN
l WOMEN=16-20/MIN
l ASSESS CHEST WALL RISING EQUAL BILATERAL,
IF THE MOVEMENT IS LABORED OR IF THE CLIENT
IS USING ACCESSORY MUSCLES TO BREATHE
drjAlo 6
13. HYPOTENSION COMMON IN ELDERLY
l ASSIST THE CLIENT TO SIT
OR STAND
l BE PREPARED TO STEADY
OR ASSIST CLIENT IF
BECOMES DIZZY
l WAIT 30 SECONDS-TAKE
B/P
l DETERMINE IF THE
SYSTOLIC B/P FALLS 20MM
Hg OR MORE, THE
DIASTOLIC FALLS 10MM Hg
OR MORE, PULSE RISE 20
BEATS OR MORE
l CHECK HX SYNCOPE,
CHEST PAIN, CHF,
PACEMAKER
drjAlo 13
15. INSPECTION-”ONCE OVER”
l OBSERVE-WHAT YOU
SEE(COLOR OF SKIN-
PINK, DUSTY,
MOTTLED, SKIN
DISCOLORED), SMELL
l STARTS DURING
HEALTH HISTORY
UNTIL END OF
EXAM(BEFORE YOU
TOUCH OR LISTEN)
l FIRST NOTE GENERAL
OBSERVATIONS
drjAlo 15
16. LOOK FOR CLUES OF POOR HEALTH
l LEVEL OF CONSCIOUSNESS
l PERSONAL HYGIENE
l NUTRITIONAL STATUS
l POSTURE, GAIT—AMBULATORY AIDS
l SYMMETRY
l APPEARANCE AND APPROPRIATENESS OF
CLOTHING
l LISTEN TO QUALITY AND APPROPRIATENESS OF
SPEECH
l OBSERVE FACIAL EXPRESSIONS-ANY EYE
CONTACT
l HOW COMFORTABLE IS CLIENT WITH
INTERPERSONAL INTERACTION
drjAlo 16
17. CONT’ CLUES
l ASSESS WHETHER AGE IS CONGRUENT
WITH APPEARANCE
l OBSERVE BODY FAT, STATURE, MOTOR
MOVEMENTS, BODY AND BREATH ODORS
l GENERAL MANNERISMS-MOOD AND
AFFECT
l LOOK FOR SIGNS OF DISTRESS-AS
EVIDENT BY BREATHING PATTERNS,
SPEECH, FACIAL EXPRESSIONS,
PERSPIRATION, TENSION, GUARDING,
BRACING AND ANXIETY
drjAlo 17
18. AUSCULTATION
l LISTENING TO
BODY SOUNDS
l HEART, LUNGS,
ABDOMEN
l ELIMINATE OR
REDUCE
ENVIRONMENTAL
NOISE
drjAlo 18
19. PERCUSSION
l STRIKING OR TAPPING A
PART OF THE BODY
l PRODUCE VIBRATORY
SOUNDS
l “AIDS IN DETERMINING
LOCATION, SIZE, AND
DENSITY OF UNDERLYING
STRUCTURES”
l CLIENT SHOULD NOT HAVE
DISCOMFORT. PAIN COULD
INDICATE DISEASE
PROCESS OR TISSUE
INJURY
l “Descriptive terms/location-EX:
normal lung = resonant”
drjAlo 19
20. PALPATION
l LIGHTLY TOUCHING OR
APPLYING DEEP PRESSURE
(1 INCH)
l USE OF FINGER TIPS, BACK
OF THE HAND, OR PALM OF
HAND
l SIZE, SHAPE,
CONSISTENCY, MOBILITY
OF NORMAL AND UNUSUAL
MASSES, SYMMETRY
l SKIN TEMPERATURE AND
MOISTURE
l ANY TENDERNESS
l UNUSUAL VIBRATIONS
drjAlo 20
21. APPROACH FOR DATA COLLECTION
l HEAD TO TOE APPROACH
l ADVANTAGES-PREVENTS OVERLOOKING
SOME ASPECT OF DATA COLLECTION, IT
REDUCES THE NUMBER OF POSITION
CHANGES REQUIRED OF THE CLIENT;
GENERALLY TAKES LESS TIME BECAUSE
THE NURSE IS NOT CONSTANTLY MOVING
AROUND THE CLIENT IN HAPHAZARD
MANNER
l BODY SYSTEM APPROACH - TO
FUNCTIONAL SYSTEM OF THE BODY-EX.
SKIN, HEART, LUNG, ETC.
drjAlo 21
22. DATA COLLECTION
l HEAD-SYMMETRY, LUMPS
l ASSESS MENTAL STATUS-
COGNITIVE STATUS, ABLE TO
THINK ABSTRACTLY, BEHAVIOR,
MOOD, LOC-ALERT, DROWSY,
STUPOROUS, COMATOSE
l RESPONSIVENESS-AWAKE,
SLEEPY, PAIN RESPONSE
l ORIENTATION-TIME, PLACE,
PERSON, YEAR, PRESIDENT
l EMOTIONAL STATE-HAPPY, SAD,
WITHDRAWN
l HX OF HEAD INJURY, SEIZURES
l HAIR-
COLOR,TEXTURE,DISTRIBUTION
EYEBROWS,
EYELAHES,SCALP(SMOOTH,
INTACT, FREE OF LESIONS, NITS;
PALPATE SKULL FOR ANY
UNUSUAL CONTOUR
drjAlo 22
23. EYE ASSESSMENT
l EYES-SIMILAR IN SIZE AND DISTANCE
FROM CENTER OF FACE
l IRIS SAME COLOR
l SCLERAE-WHITE
l CORNEAS-CLEAR
l EYELASHES PRESENT
l ADVANCE EXAM-USE A
OPHTHALMOSCOPE
l VISUAL ACUITY-ABLE TO SEE BOTH
FAR AND NEAR; WEAR GLASSES OR
CONTACT LENS; FALSE EYE; BLIND
l FAR (central)VISION-ASK CLIENT TO
STATE(SNELLEN CHART-READ
LETTERS) HOW MANY FINGERS ARE UP
FROM 20 FEET AWAY. “ex: 20/40-ONE
THAT PEOPLE WITH NORMAL VISION
CAN SEE FROM 40 FT AWAY”
l CLOSE VISION- “(Jaeger Chart)HAVE
THEM READ NEWSPAPER FROM
APPROXIMATELY 14 INCHES away”
drjAlo 23
24. PERRLA – PUPILS EQUALLY ROUND
AND REACT TO LIGHT AND
ACCOMODATION
l PUPILS ARE MEASURED IN
MILLIMETER
l DIM LIGHTS-MOVE LIGHT FROM
TEMPLE TOWARD EYE; OBSERVE
PUPIL AS WELL AS UNSTIMULATED
PUPIL; REPEAT IN OTHER EYE;
ASK CLIENT TO LOOK AT FINGER
OR OBJECT 4 INCHES FROM FACE-
LOOK NEAR AND FAR
l CONSENSUAL RESPONSE(BRISK,
EQUAL, SIMULTANEIOUS
CONSTRICTION WITH LIGHT)
“Notices the other pupil reacts
simultaneously”
l ACCOMMODATION(ABILITY TO
CONSTRICT WHEN LOOKING AT A
NEAR OBJECT AND DILATE WHEN
LOOKING AT AN OBJECT IN THE
DISTANCE
l “Head injury-the nurse assesses
client’s pupillary response.”
drjAlo 24
25. EYE ASSESSMENT
l EXTRAOCULAR
MOVEMENTS-CAN THE
CLIENT FOCUS AND TRACK
MOVING OBJECT-EYES
SHOULD MOVE IN
COORDINATED MANNER.
NO MOVE IN ONE EYE MAY
INDICATE CRANIAL NERVE
DAMAGE; IRREGULAR OR
UNCOORDINATED
MOVEMENT MAY SUGGEST
OTHER NEUROLOGIC
PATHOLOGY
drjAlo 25
26. PERIPHERAL VISION ASSESS
l GROSS ASSESSMENT-
NURSE STANDS
DIRECTLY IN FRONT
OF THE CLIENT.
NURSE INSTRUCTS
CLIENT TO LOOK
STRAIGHT AHEAD AND
INDICATE WHEN HE OR
SHE SEES A LIGHT OR
THE NURSE’S FINGER
AS THE NURSE BRINGS
IT FROM SEVERAL
SECTORS OF THE
PERIPHERY TOWARD
THE CENTER
drjAlo 26
28. EARS
l INSPECT-(child=pull ear down and back;
ADULT=pull ear up and back), PALPATE
THE EXTERNAL EAR, INCLUDING
ALIGNMENT(TOP OF EAR CROSSES AN
IMAGINARY LINE FROM EYE TO
OCCIPUT),
l “Normal to have some cerumen”
l CHECK FOR TAGS, EXCESS WAX,
DRAINAGE, DEFORMITIES, NODULES,
INFLAMMATION, PAIN, TENDER OR
“BOGGY” MASTOID
l OBSERVE THE SHAPE, COLOR, SIZE OF
THE EAR
l OTOSCOPIC-START AT EAR CANAL,
TYMPANIC MEMBRANE AND ITS
MOVEMENT-CHECK FOR INFECTIONS
l HEARING ACUITY-NOTE RESPONSES
TO SOUND-VOICE/WHISPER OR WATCH
TICK 1-2 FEET. CONDUCT WEBER AND
RHINNE TEST(TUNING FORK) “If the client
does not continue to hear sound when the
tuning fork is beside the ear, it indicates a
problem with the ear structure that collect
and transmit sound through the ear.”
l DOES CLIENT USE ANY AIDS?
drjAlo 28
30. NOSE
l SEPTUM SHOULD BE MIDLINE, CAUSING THE NASAL
PASSAGES TO BE EQUAL IN SIZE-PRESS TIP OF NOSE FOR
DEEPER INSPECTION. HAVE CLIENT INHALE AND EXHALE
THROUGH EACH NOSTRIL
l AIR SHOULD MOVE FAIRLY QUIETLY
l MUCOUS MEMBRANE-PINK, MOIST, FREE OF OBVIOUS
DRAINAGE
l ABNORMAL-DEVIATED SEPTUM, LESIONS, GROWTHS,
FLARING OF THE NOSTRILS, UNUSUAL DRAINAGE
l SMELLING ASSESS-IDENTIFY ODORS-HAVE CLIENT CLOSE
EYES-OCCLUDE ONE NOSTRIL AT A TIME-PLACE
SUBSTANCES-VANILLA, COFFEE, ETC HAVE THEM IDENTIFY
THE SMELL AFTER INHALING (TEST CN-I=OLFACTORY
NERVE)
drjAlo 30
31. MOUTH AND ORAL MUCOUS
MEMBRANE
l EXAMINE THE
MOUTH(PINK/MOIST),
TEETH(COUNT),
TONGUE(MIDLINE), AND THROAT
l INSPECT AND PALPATE
LIPS(SYMMETRICAL), GUMS,
TONGUE PROTRUSION, HARD AND
SOFT PALATE, TONSILS, UVULA
POSITION AND MOVEMENT-
IDENTIFY LESIONS, COLOR OF
MEMBRANES, CAVITIES,
ODORS,SWELLING,
INFLAMMATION, SWALLOWING
DIFFICULITIES, CLEAR VOICE
l CONDUCT GAG REFLEX
RESPONSE, TASTE TEST FOR
SWEET, SOUR, BITTER, AND SALT.
l DENTURES(FIT PROPERLY),
PARTIAL, BRIDGE
drjAlo 31
33. NECK
l INSPECT AND PALPATE THE TRACHEA. DOES IT
RUN MIDLINE?
l PALPATE THE NECK/LYMPH NODES-CHECK FOR
GOITER, NODULES, ENLARGEMENTS OR
TENDERNESS IN THE NECK AND THYROID.
l PALPATE THE TEMPORAL AND CAROTID PULSES.
ASSESS THE QUALITY, CHARACTER, RHYTHM, AND
STRENGTH OF THE PULSE
l BEND HEAD FORWARD, BACKWARD, TO EITHER
SIDE AS WELL AS ROTATE 180 DEGREE
l THERE SHOULD BE NO UNUSUAL BULGES OR
FULLNESS IN THE NECK
drjAlo 33
34. FACIAL SKIN AND SKIN INTEGRITY OF
THE BODY
l WOUND=BREAK IN THE SKIN
l ULCER=OPEN CRATER-LIKE AREA
l ABRASION=AREA THAT HAS BEEN
RUBBED AWAY BY FRICTION
l LACERATION=TORN, JAGGED WOUND
l FISSURE=CRACK IN THE SKIN ESP. IN
OR NEAR A MUCOUS MEMBRANES
l SCAR=MARK LEFT BY THE HEALING
OF A WOUND OR LESION
drjAlo 34
41. UPPER NEUROMUSCULAR
EXAMINATION
l INSPECT AND PALPATE MUSCLES, BONES, AND JOINTS.
l SYMMETRICAL, SIZE, TONE, RANGE OF MOTION.
l ASSESS STRENGTH USING RESISTIVE ROM.
l EXAMINE THE CERVICAL SPINE-FLEX, EXTEND
l EXAMINE THE SHOULDERS-FLEX, HYPEREXTEND, ABDUCT,
ADDUCT, TURN ININTERNAL AND EXTERNAL ROTATION,
SHRUG AND PUSH/PULL AGAINST THE SHOULDER
l EXAMINE WRISTS, ELBOWS-FLEX, EXTEND, ROTATE
l HAND GRIPS
l FINGERS-ABDUCT/ADDUCT. PERFORM FINGER THUMB
OPPOSITION COUNTING
l CHECK FOR TENDERNESS/MOBILITY
drjAlo 41
43. CHEST AND BREAST EXAMINATION
l INSPECT AND PALPATE
BREAST, NIPPLE, AND
AREOLA. PALPATE THE
AXILLARY LYMPH NODES-
DETECT LUMPS, NODULES,
TENDERNES,DISCHARGE
l Breast exam-massage small
circles or a spokes of a wheel
“outer margins of the breast tp the
nipple.”
l OBSERVE THE SHAPE OF THE
CHEST AND HOW IT MOVES
DURING BREATHING
l TURGOR- elastic
quality(RESILIENCY OF SKIN)
INDICATES HYDRATION.
(>3SEC ABNORMAL-prolonged
tenting sign of dehydration)
drjAlo 43
44. CHEST SHAPE AND MOVEMENT
l LATERAL DIMENSION
OF THE CHEST IS
APPROX. TWICE THE
ANTERIOR-POSTERIOR
DIMENSIONS
l ABNORMALITIES OF
HEART AND LUNG CAN
CAUSE CHEST TO
CHANGE SHAPE
l NORMAL BREATHING,
CHEST EXPANDS
EQUALLY ON BOTH
SIDES
drjAlo 44
45. SPINE OR COLUMN OF VERTEBRAE
l MIDLINE WITH GENTLE
CONVEX CURVES WHEN
VIEWED FROM THE SIDE
l SHOULDERS EQUAL IN
HEIGHT
l “SCOLIOSIS-LATERAL
CURVATURE”
l LORDOSIS-NATURAL
LUMBAR CURVE OF THE
SPINE IS EXAGGERATED
l KYPHOSIS-INCREASED
CURVE IN THE THORACIC
AREA
drjAlo 45
46. HEART
l A= AORTIC AREA
l P= PULMONIC AREA
l T= TRICUSPID AREA
l M=MITRAL AREA(APICAL)(PMI-
loudest sound)
l “S1”=LUB
l S2=DUB
l S3 NOT NORMAL IN ADULTS
BUT NORMAL IN CHILDREN.
SOUNDS LIKE LUB-DUB-DUB
(KEN-TUCK-Y)
l S4 LUB-LUB-DUB(BEFORE S1)
TEN-NES-SEE (ABNORMAL)
l LISTEN FOR ABNORMAL
MURMURS, CLICKS, RUBS
drjAlo 46
47. LUNG SOUNDS
l AIR MOVING IN OUT
OF AIR
PASSAGEWAYS
l SOUNDS VARY IN
PITCH AND
DURATION IN
RELATION TO THE
SIZE AND
LOCATION OF THE
AIR PASSAGES
drjAlo 47
48. NORMAL LUNG SOUNDS
l TRACHEAL SOUNDS-LOUD AND
COARSE; EQUAL IN LENGTH
DURING INSPIRATION AND
EXPIRATION AND ARE SEPARATED
BY A BRIEF PAUSE
l BRONCHIAL SOUNDS-HEARD
UPPER PART OF STERNUM AND
BETWEEN SCAPULAE, ARE HARSH
AND LOUD.
l BRONCHOVESICULAR SOUNDS-
HEARD EITHER SIDE OF CHEST-
MEDIUM RANGE SOUNDS OF
EQUAL LENGTH DURING
INSPIRATION AND EXPIRATION
WITH NO NOTICEABLE PAUSE
l “VESICULAR SOUNDS LOCATED IN
THE PERIPHERY OF ALL LUNG
FIELDS”. THEY ARE SOFT,
RUSTLING QUALITY IS LONGER ON
INSPIRATION THAN EXPIRATION,
WITH NO PAUSE BETWEEN.
drjAlo 48
49. ABNORMAL LUNG SOUNDS
l CRACKLES/RALES ARE INTERMITTENT, HIGH PITCHED, POPPING SOUNDS
HEAD IN DISTANT AREA OF THE LUNGS PRIMARILY DURING INSPIRATION.
RESEMBLE RICE KRISPIES WITH MILK ADDED. SOUNDS ATTRIBUTED TO THE
OPENING OF PARTIALLY COLLAPSED ALVEOLI
l GURGLES /RHONCHI LOW PITCHED, CONTINUOUS, BUBBLING SOUNDS
HEAD IN LARGER AIRWAY. PROMINENT ON EXPIRATION. WET SNORING
SOUND. MAY CLEAR AFTER YOU GET CLIENT TO COUGH
l WHEEZES WHISTLING OR SQUEAKING SOUNDS BY AIR MOVING THROUGH
A NARROWED PASSAGE. HEARD ANY WHERE THROUGHTOUT THE CHEST
DURING INSPIRATION AND EXPIRATION. SOME ARE AUDIBLE WITHOUT
STETOSCOPE. COUGHING AND DEEP BREATHING DO NOT ALTER A WHEEZE.
IN FACT IF WHEEZING SUDDENLY STOPS, IT MAY MEAN THAT THE AIR
PASSAGES IS TOTALLY OCCLUDED.
l RUBS GRATING OR LEATHERY SOUNDS CAUSED BY TWO DRY PLEURAL
SURFACES MOVING OVER EACH OTHER.
l DIMINISED
l Watch for cyanosis, pursed lips,
l ALWAYS INSPECT SPUTUM (esp. if client has a cough)-COLOR, AMOUNT,
ODOR, CONSISTENCY REQUIRING SUCTION, OXYGEN, PULSE OXIMETRY,
TRACHEOSTOMY
drjAlo 49
50. ABDOMEN
l INSPECT SIZE(MEASURE GIRTH),
CONTOUR(DISTENDED, HARD, SOFT),
SYMMETRY
l NOTE PIGMENTATION, SCARS, STRIAE,
MASSES, NODULES, CONDITION OF
UMBILICUS, ANY RESPIRATORY OR
PERISTALTIC MOVEMENT(LAST BM)
l LISTEN FOR BOWEL SOUNDS IN EACH 4
QUADRANTS-CLICKS AND GURGLES OCCURS
5-34/MIN; HYPER^; HYPO-LONG INTERVAL OF
SILENCE AND ABSENT IF NO SOUND HEARD
FOR 2-5 MINUTES
l PERCUSS RLQ, RUQ, GASTRIC BUBBLES,
SPLEEN, BLADDER, LLQ, LUQ, LIVER SPAN
l PALPATE FIRST SUPERFICIALLY THEN DEEP
AND REBOUND PALPATIONS TO IDENTIFY ANY
DISCOMFORT TENDERNESS, OR
ABNORMALITIES. EVALUATE FOR GUARDING
ON EXPIRATION
l NAUSEA, VOMITING, FLATULENCE
l PRESENCE OF HERNIA, COLOSTOMY,
ILEOSTOMY, GASTROSTOMY
l NUTRITIONAL APPROACH-ORAL, FEEDING, IV
l CHECK FEMORAL PULSES(SYMMETRICAL AND
EVEN) AND SUPERFICIAL AND DEEP INGUINAL
NODES(NORMAL,1CM, MOVABLE AND
NONTENDER)
drjAlo 50
53. GENITOURINARY SYSTEM
l ASK CLIENT VOIDING-ANY BURNING,
FREQUENCY,INCONTINENCE, NOCTURIA(HOW
MANY TIMES), RETENTION, CATHETER
l NOTE URINE-COLOR(YELLOW, CLOUDY,
FOAMY), ODOR
l MENOPAUSE SYMPTOMS
l LMP
l OBSERVE PUBIC HAIR DISTRIBUTION, COLOR,
TEXTURE
l CHECK FOR SKIN ABNORMALITIES-IN WOMAN-
EXAMINE MONS PUBIS, LABIA MAJORA, LABIA
MINORA, CLITORIS, URETHRAL MEATUS,
VAGINAL INTROITUS, AND PERINEUM
l IN MEN-CHECK URETHRAL MEATUS,
PENIS(GLANS, FORESKIN, SHAFT), SCROTOM
RUGAE, TESTICLES
l CHECK FOR ABNORMAL LESIONS, ODOR,
SWELLING, INFLAMMATION, NODULES,
CONDYLOMA, VESICLES, PUSTULES, SCALING,
EDEMA
l EXAMINE ANUS-FREE OF LESIONS,
SWELLING,INFLAMMATION, TENDERNESS,
ITCHING, FISSURES, RASHES, MASSES,
HEMORRHOIDS, OR SKIN TAGS
drjAlo 53
54. LOWER EXTREMITY AND
MUSCULOSKELETAL EXAMINATION
l HAVE CLIENT WALK ACROSS ROOM WHILE OBSERVING GAIT-NORMAL, UNSTEADY,
POOR SITTING/STANDING BALANCE, DIZZINESS (FALL ASSESSMENT) ANY
AMPUTATIONS, WT BEARING LIMITATIONS, PROSTHESIS, AMB. AIDS
l INSPECT AND PALPATE THE SKIN. CHECK CAPILLARY REFILL- toenails (3 SEC);
OBSERVE FOR HAIR DISTRIBUTION, VEINS, TEMPERATURE AND TEXTURE OF SKIN,
toenails for fungal infection, inflammation
l DETECTS SKIN ATROPHY, BREAKDOWN, EDEMA, ULCERATIONS, OR VARICOSE VEINS.
l OBSERVE THE SIZE, SHAPE, ISOMETRIC MUSCLE CONTRACTION, TONE,
STRENGTH(USING RESISTIVE ROM) OF MUSCLES
l DETERMINES THAT MUSCLE SHAPE IS SYMMETRIC, WITH GOOD TONE. DETECTS
ATROPHY, HYPERTROPHY, FLACCIDITY, SPASTICITY, SPASM, MASSES,OR
INVOLUNTARY MOVEMENTS.
l INSPECT THE JOINTS-CONFIRMS JOINTS ARTICULATE IN PROPER ALIGNMENT AND
FREE FROM SWELLING, NODULES, PAIN, WARMTH, DEFORMITIES, MASSES, CRACKLING
SOUND(CREPITUS), GRATING OR POPPING. EVALUATES FOR CONTRACTURES.
l PALPATE ACHILLES TENDON-DORSIFLEX AND PLANTAR FLEX-EVALUATES CLONUS,
DEEP VEIN THROMBOS
l CHECK POPLITEAL, POSTERIOR TIBIAL, AND DORSALIS PEDIS PULSES
drjAlo 54
59. PHYSICAL ASSESSMENT
l COMPARE THE CLIENT’S STATUS TO AGE-APPROPRIATE
STANDARDS FOR ACTIVITIES OF DAILY LIVING (ADLs), GROSS AND
FINE MOTOR FUNCTION, SPEECH AND LANGUAGE, AND PERSONAL-
SOCIAL INTERACTION
l PAIN-”DO YOU HAVE PAIN NOW?” LAST 7 DAYS? WHEN DO YOU
HURT MOST? PAIN AFFECTS? DESCRIBE PAIN? WHAT RELIEVES?
PAIN SCALE 0-5
l SLEEP PATTERN
l MEDICATIONS-ANTIPSYCHOTIC, ANTIANXIETY, ANTIDEPRESSANT,
HYPNOTIC, DIURETIC
l SPECIAL TREATMENTS-CHEMOTHERAPY, DIALYSIS,
TRANSFUSIONS, IV MED, RADIATION,
l IF CLIENT UNABLE TO ANSWER QUESTIONS-NOTE FACIAL
EXPRESSIONS, BREATHING, BEHAVIOR, VOCAL BEHAVIOR, BODY
MOVEMENTS, CHANGES IN ADL’S, INDICATORS OF PAIN
l CONFIRMS HEALTH AND IDENTIFIES SIGNS AND SYMPTOMS OF
ILLNESS OR DISEASE
drjAlo 59
60. PSYCHIATRIC ASSESSMENT
l DISTURBED AFFECT
l AVERSIVE EYE CONTACT
l SYMPTOMS OF DEPRESSION OR
ANXIETY
l DISRUPTED OR CONFUSED THOUGHT
PROCESSES
l INDICATIONS OF DELUSIONAL
THOUGHTS
l INDICATIONS OF SUICIDAL THOUGHYS
drjAlo 60
61. SEXUAL HISTORY ASSESSMENT
l EXPLAIN TO CLIENT YOU WILL BE ASKING
QUESTIONS PERTAINING TO HIS OR HER SEX LIFE
TO IDENTIFY PROBLEMS THAT COULD BE
IMPROVED AND TO LEARN ABOUT POSSIBLE
EXISTING CONDITIONS THAT COULD BE REVEALED
THROUGH SEXUAL PROBLEMS. ASK ELDER FOR
PERMISSION TO CONTINUE;
l ARE YOU SEXUALLY ACTIVE?
l IF NO, ASK FOR REASON(NO PARTNER, NO
ENERGY, ERECTILE DYSFUNCTION)
l BASED ON THE REASON, INQUIRE ABOUT THE
ELDER’S INTEREST IN CHANGING THE SITUATION
TO BECOME SEXUALLY ACTIVE AND RECOMMEND
PLANS ACCORDINGLY
drjAlo 61
62. SEXUAL ASSESSMENT
l IF THE ANSWER IS YES
l HOW FREQUENTLY DO YOU HAVE SEX? IS
THIS A SATISFYING FREQUENCY FOR YOU?
IF NOT, HOW WOULD YOU CHANGE THE
FREQUENCY OF SEX/
l DO YOU HAVE SEX WITH A SINGLE OR
MULTIPLE PARTNERS? MALE OR FEMALE
PARTNER?
l IF YOU HAVE SEX WITH NEW PARTNERS,
DO YOU USE A CONDOM?
l DO YOU OBTAIN PLEASURE FROM SEX? IF
NOT, WHY NOT?
drjAlo 62
