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
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• vital signs/ height & weight
Helpful Hints
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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
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Equipment needed
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Client and environment readiness
Techniques for examination
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Inspect general appearance
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skin color
consistency of general appearance with age
general state of nutrition
hygiene
obvious physical deformities, limitations, use of assistive devices
Techniques for examination
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Inspect stature and
movement
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symmetry
posture
body build
mobility
Techniques for examination
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Inspect demeanor
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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
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Upper extremities
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Spine
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HEENT including face & neck
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Lungs (anterior, posterior, &
lateral)
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Cranial nerves
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Heart
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Breast
Have the client lie in a supine position with the examiner at
the client’s right side examine the following:
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Breasts
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Heart
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Abdomen
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Lower extremities
Have the client resume a sitting position with the examiner
standing in front of the client and assess the following:
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Neural system
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deep tendon reflexes (DTR’s)
cerebellar function
sensory function
two-point discrimination
stereognosis, graphesthia
position sense
With the client still seated complete the
following
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Assessment of upper extremities
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strength
range of motion
sensation
vibration
position sense
With the client in the standing position
assess the following
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Examination of spine and sacral area
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The remainder of the neural system evaluation
• inspect gait
• assess proprioception and cerebellar function
Genitalia Examination
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For the male client the following are assessed with the client in a
standing position
• external genitalia
• presence of hernia
• rectal exam
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For the female client the exam is done with the client in the lithotomy
position
Documentation
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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