PHYSICAL ASSESSMENTSYSTEMATIC EXAMINATION OF BODY STRUCTURES

IDENTIFY THE CLIENT/ REVIEW CLIENTS MEDICAL HISTORY DETERMINE THE CLIENTS AGE, GENDER, AND RACE OBSERVE THE CLIENTS STATE OF ALERTNESS AND ABILITY TO MOVE; physical appearance in relation to their clothing and hygiene ASK A CLIENTS 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 CLIENTS QUESTIONS DR. JAMES M. ALO, RN, MAN,MAP, PHD

PHYSICAL ASSESSMENT/ ENVIRONMENT

l ORGANIZE EQUIPMENT l Easy access to a restroomempty 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

EQUIPMENT

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PURPOSES-gather objective data from client

l OBTAIN BASELINE MEASUREMENTS/FOR FUTURE COMPARISONS l COMPARE WITH NORMAL DATA (VARY WITH AGENORMAL TEMPERATURE DO NOT RULE OUT ILLNESS, ESP. YOUNG OR ELDERLY l EVALUATE CLIENTS CURRENT PHYSICAL CONDITION l DETECT EARLY SIGNS OF DEVELOPING HEALTH PROBLEMS l TO EVALUATE THE CLIENTS RESPONSES TO MEDICAL AND NURSING INTERVENTIONS
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VITAL SIGNS
l BODY TEMPERATURE l PULSE RATE l RESPIRATORY RATE l BLOOD PRESSURE

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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
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PERIPHERAL PULSE SITES

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APICAL HEART RATE (loudest sound)TO THE LEFT OF THE STERNUM AT THE INTERSPACE BELOW THE 5TH RIB IN MIDLINE TO CLAVICLE

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APICAL-RADIAL RATE-SHOULD BE THE SAME, IF NOT CHECK PULSE DEFICIT-REPORT FINDINGS PROMPT

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PULSE

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NORMAL AND ABNORMAL RESPIRATORY PATTERNS

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BLOOD PRESSURE

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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
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ASSESSMENT TECHNIQUES
l INSPECTION-1st-scan client l AUSCULTATION-2nd l PERCUSSION l PALPATION l What do you do first? Than second?

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INSPECTION-ONCE OVER
l OBSERVE-WHAT YOU SEE(COLOR OF SKINPINK, DUSTY, MOTTLED, SKIN DISCOLORED), SMELL l STARTS DURING HEALTH HISTORY UNTIL END OF EXAM(BEFORE YOU TOUCH OR LISTEN) l FIRST NOTE GENERAL OBSERVATIONS
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LOOK FOR CLUES OF POOR HEALTH

LEVEL OF CONSCIOUSNESS PERSONAL HYGIENE NUTRITIONAL STATUS POSTURE, GAITAMBULATORY AIDS SYMMETRY 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 l l l l l l
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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
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AUSCULTATION
l LISTENING TO BODY SOUNDS l HEART, LUNGS, ABDOMEN l ELIMINATE OR REDUCE ENVIRONMENTAL NOISE

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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
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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
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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.
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DATA COLLECTION
l HEAD-SYMMETRY, LUMPS l ASSESS MENTAL STATUSCOGNITIVE 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 HAIRCOLOR,TEXTURE,DISTRIBUTION EYEBROWS, EYELAHES,SCALP(SMOOTH, INTACT, FREE OF LESIONS, NITS; PALPATE SKULL FOR ANY UNUSUAL CONTOUR
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EYE ASSESSMENT
l l l l l l l l EYES-SIMILAR IN SIZE AND DISTANCE FROM CENTER OF FACE IRIS SAME COLOR SCLERAE-WHITE CORNEAS-CLEAR EYELASHES PRESENT ADVANCE EXAM-USE A OPHTHALMOSCOPE VISUAL ACUITY-ABLE TO SEE BOTH FAR AND NEAR; WEAR GLASSES OR CONTACT LENS; FALSE EYE; BLIND 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 CLOSE VISION- (Jaeger Chart)HAVE THEM READ NEWSPAPER FROM APPROXIMATELY 14 INCHES away

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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 FACELOOK 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 clients pupillary response.
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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

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PERIPHERAL VISION ASSESS

l GROSS ASSESSMENTNURSE 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 NURSES FINGER AS THE NURSE BRINGS IT FROM SEVERAL SECTORS OF THE PERIPHERY TOWARD THE CENTER
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EYES

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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), Normal to have some cerumen CHECK FOR TAGS, EXCESS WAX, DRAINAGE, DEFORMITIES, NODULES, INFLAMMATION, PAIN, TENDER OR BOGGY MASTOID OBSERVE THE SHAPE, COLOR, SIZE OF THE EAR OTOSCOPIC-START AT EAR CANAL, TYMPANIC MEMBRANE AND ITS MOVEMENT-CHECK FOR INFECTIONS 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. DOES CLIENT USE ANY AIDS?
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INNER EAR

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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)

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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 MOVEMENTIDENTIFY 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

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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
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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
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DECUBITUS STAGES

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SKIN

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VASCULAR LESIONS

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VASCULAR LESIONS

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VASCULAR LESIONS

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UPPER NEUROMUSCULAR EXAMINATION

l l l l l l l l l INSPECT AND PALPATE MUSCLES, BONES, AND JOINTS. SYMMETRICAL, SIZE, TONE, RANGE OF MOTION. ASSESS STRENGTH USING RESISTIVE ROM. EXAMINE THE CERVICAL SPINE-FLEX, EXTEND EXAMINE THE SHOULDERS-FLEX, HYPEREXTEND, ABDUCT, ADDUCT, TURN ININTERNAL AND EXTERNAL ROTATION, SHRUG AND PUSH/PULL AGAINST THE SHOULDER EXAMINE WRISTS, ELBOWS-FLEX, EXTEND, ROTATE HAND GRIPS FINGERS-ABDUCT/ADDUCT. PERFORM FINGER THUMB OPPOSITION COUNTING CHECK FOR TENDERNESS/MOBILITY

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UPPER NEUROMUSCULAR EXAM

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CHEST AND BREAST EXAMINATION

l INSPECT AND PALPATE BREAST, NIPPLE, AND AREOLA. PALPATE THE AXILLARY LYMPH NODESDETECT 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)
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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
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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

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HEART
l l l l l l l A= AORTIC AREA P= PULMONIC AREA T= TRICUSPID AREA M=MITRAL AREA(APICAL)(PMIloudest sound) S1=LUB S2=DUB S3 NOT NORMAL IN ADULTS BUT NORMAL IN CHILDREN. SOUNDS LIKE LUB-DUB-DUB (KEN-TUCK-Y) S4 LUB-LUB-DUB(BEFORE S1) TEN-NES-SEE (ABNORMAL) LISTEN FOR ABNORMAL MURMURS, CLICKS, RUBS

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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
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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 SOUNDSHEARD EITHER SIDE OF CHESTMEDIUM 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.
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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
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ABDOMEN
l l INSPECT SIZE(MEASURE GIRTH), CONTOUR(DISTENDED, HARD, SOFT), SYMMETRY NOTE PIGMENTATION, SCARS, STRIAE, MASSES, NODULES, CONDITION OF UMBILICUS, ANY RESPIRATORY OR PERISTALTIC MOVEMENT(LAST BM) 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 PERCUSS RLQ, RUQ, GASTRIC BUBBLES, SPLEEN, BLADDER, LLQ, LUQ, LIVER SPAN PALPATE FIRST SUPERFICIALLY THEN DEEP AND REBOUND PALPATIONS TO IDENTIFY ANY DISCOMFORT TENDERNESS, OR ABNORMALITIES. EVALUATE FOR GUARDING ON EXPIRATION NAUSEA, VOMITING, FLATULENCE PRESENCE OF HERNIA, COLOSTOMY, ILEOSTOMY, GASTROSTOMY NUTRITIONAL APPROACH-ORAL, FEEDING, IV CHECK FEMORAL PULSES(SYMMETRICAL AND EVEN) AND SUPERFICIAL AND DEEP INGUINAL NODES(NORMAL,1CM, MOVABLE AND NONTENDER)

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ABDOMEN

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ABDOMEN

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GENITOURINARY SYSTEM
l l l l l l ASK CLIENT VOIDING-ANY BURNING, FREQUENCY,INCONTINENCE, NOCTURIA(HOW MANY TIMES), RETENTION, CATHETER NOTE URINE-COLOR(YELLOW, CLOUDY, FOAMY), ODOR MENOPAUSE SYMPTOMS LMP OBSERVE PUBIC HAIR DISTRIBUTION, COLOR, TEXTURE CHECK FOR SKIN ABNORMALITIES-IN WOMANEXAMINE MONS PUBIS, LABIA MAJORA, LABIA MINORA, CLITORIS, URETHRAL MEATUS, VAGINAL INTROITUS, AND PERINEUM IN MEN-CHECK URETHRAL MEATUS, PENIS(GLANS, FORESKIN, SHAFT), SCROTOM RUGAE, TESTICLES CHECK FOR ABNORMAL LESIONS, ODOR, SWELLING, INFLAMMATION, NODULES, CONDYLOMA, VESICLES, PUSTULES, SCALING, EDEMA EXAMINE ANUS-FREE OF LESIONS, SWELLING,INFLAMMATION, TENDERNESS, ITCHING, FISSURES, RASHES, MASSES, HEMORRHOIDS, OR SKIN TAGS

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LOWER EXTREMITY AND MUSCULOSKELETAL EXAMINATION

l l l l l l l 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 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 DETECTS SKIN ATROPHY, BREAKDOWN, EDEMA, ULCERATIONS, OR VARICOSE VEINS. OBSERVE THE SIZE, SHAPE, ISOMETRIC MUSCLE CONTRACTION, TONE, STRENGTH(USING RESISTIVE ROM) OF MUSCLES DETERMINES THAT MUSCLE SHAPE IS SYMMETRIC, WITH GOOD TONE. DETECTS ATROPHY, HYPERTROPHY, FLACCIDITY, SPASTICITY, SPASM, MASSES,OR INVOLUNTARY MOVEMENTS. 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. PALPATE ACHILLES TENDON-DORSIFLEX AND PLANTAR FLEX-EVALUATES CLONUS, DEEP VEIN THROMBOS CHECK POPLITEAL, POSTERIOR TIBIAL, AND DORSALIS PEDIS PULSES

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MUSCULOSKELETAL

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Musculoskeletal strength

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DOCUMENTING EDEMA

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LOWER EXTREMITY

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PHYSICAL ASSESSMENT
l COMPARE THE CLIENTS STATUS TO AGE-APPROPRIATE STANDARDS FOR ACTIVITIES OF DAILY LIVING (ADLs), GROSS AND FINE MOTOR FUNCTION, SPEECH AND LANGUAGE, AND PERSONALSOCIAL 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 ADLS, INDICATORS OF PAIN l CONFIRMS HEALTH AND IDENTIFIES SIGNS AND SYMPTOMS OF ILLNESS OR DISEASE

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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
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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 ELDERS INTEREST IN CHANGING THE SITUATION TO BECOME SEXUALLY ACTIVE AND RECOMMEND PLANS ACCORDINGLY
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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?
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l Thank You

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