Upload
rootie
View
248
Download
0
Embed Size (px)
Citation preview
8/10/2019 Head to Toe Assessement
1/97
HEALTH
ASSESSMENT
HEAD TO TOE PHYSICAL
EXAMINATION
8/10/2019 Head to Toe Assessement
2/97
HEALTH ASSESSMENT
DEFINITION:
Health assessment or clinical examination (more
popularly known as a check-up) is the process by
which a doctor investigates the body of a patient for
signs of disease.
8/10/2019 Head to Toe Assessement
3/97
HEALTH
HISTORY
PHYSICAL
ASSESSMENT
8/10/2019 Head to Toe Assessement
4/97
HEALTH HISTORY
A health history is the collection of subjective datathat provides a detailed profile of the patient health
status. Therapeutic communication skill and interview
technique used to gather health history.
It helps to identify actual and potential healthproblem.
8/10/2019 Head to Toe Assessement
5/97
Physical examination is an integral part of healthexamination and it includes head to toe examinationof the patient to rule out any deviation from the
normal.
PHYSICAL EXAMINATION
8/10/2019 Head to Toe Assessement
6/97
PURPOSETo gather baseline data.
To confirm the alterations, disease or inability toperform the activities of daily living.
To supplement data obtained in the nursing history.
To make nursing diagnosis.To make clinical judgments about the clientschanging health status and management.
To evaluate the effectiveness of health care.
.
8/10/2019 Head to Toe Assessement
7/97
PREPARATIONS
Comfort
Position,gowning
Height of
examinationtable
Lightsources
Eliminatedistractions
Equipments:clean & inworking
condition
http://www.casualtysimulation.com/gallery/d/989-2/physical_assessment_kit8/10/2019 Head to Toe Assessement
8/97
INSTRUMENTSSUPPLIES PURPOSE
Flash light or
penlight
To assist viewing of the pharynx and
cervix or to determine the reactions
of the pupils of the eye
Nasal speculum to visualization of the lower and
middle turbinates
Opthalmoscope To visualize the interior of the eye
Otoscope To visualized the ear drum and
external auditory canal
Knee hammer To test reflex
http://www.casualtysimulation.com/gallery/d/989-2/physical_assessment_kithttp://www.casualtysimulation.com/gallery/d/989-2/physical_assessment_kit8/10/2019 Head to Toe Assessement
9/97
INSTRUMENTSSUPPLIES PURPOSE
Tuning fork To test hearing acuity and vibratory sense.
Vaginal speculum To assess cervix and vagina
Cotton applicator To obtain specimens
Gloves To prevent contamination
Lubricant To ease insertion of instruments
Tongue depressors To depress the tongue
Stethoscope To auscultate heart, lung, abdomen and
cardiovascular sound.
Thermometer To check the temperature
http://www.casualtysimulation.com/gallery/d/989-2/physical_assessment_kit8/10/2019 Head to Toe Assessement
10/97
8/10/2019 Head to Toe Assessement
11/97
8/10/2019 Head to Toe Assessement
12/97
8/10/2019 Head to Toe Assessement
13/97
POSITIONS OF PATIENT
2. PRONE POSITION:
1. SUPINE POSITION:
8/10/2019 Head to Toe Assessement
14/97
3. SITTING POSITION:
4. SEMI FOWLERs POSITION:
8/10/2019 Head to Toe Assessement
15/97
5. SIMs POSITION:
6. KNEE-CHEST POSITION:
8/10/2019 Head to Toe Assessement
16/97
7. DORSAL RECUMBENT POSITION:
8. LITHOTOMY POSITION:
8/10/2019 Head to Toe Assessement
17/97
9. TRENDELENBERGs POSITION:
8/10/2019 Head to Toe Assessement
18/97
METHODS OF EXAMINING:
1. Inspection:
A method of systematic observation. Inspectionshould begin with general observation of the patientprogressing to specific body areas.
8/10/2019 Head to Toe Assessement
19/97
2. Palpation:Process of examining patients by application of thehands.
Used to determine:
Consistency of tissue.
Alignment and intactness
of structures.
Symmetry of body parts.
Areas of warmth and
tenderness.
8/10/2019 Head to Toe Assessement
20/97
Parts of hands used for variouspalpation:
Part of hand Type of palpation
Finger tips To assess texture, shape,size, consistency andpalpation
Dorsum of hand andfingers
To assess temperature
Palm of hand To assess vibration
Pinching of fingers To assess turgor,consistency and position
8/10/2019 Head to Toe Assessement
21/97
For light palpation, press the skin gently with the tips oftwo or three fingers held close together.
8/10/2019 Head to Toe Assessement
22/97
3. Percussion:Tapping of the body lightly but sharply to determineconsistency of tissues and/or organs through
vibration `& areas of tenderness.
8/10/2019 Head to Toe Assessement
23/97
PERCUSSION
The sounds may be:
Resonance: a low pitched and loud soundheard over the normal lung tissues.
Hyper resonance: very loud , very lowpitched sound longer than resonancesignifies emphysema.
Tympany :a drum like sound heard overthe air filled tissues such as gastric air
bubble. Dull: A medium pitched sound with amedium duration without resonanceheard over solid tissues such as heart ,
liver.
8/10/2019 Head to Toe Assessement
24/97
Percussion sound with examples:
Percussion
sounds
Intensity Pitch Percussion
example
Dullness Medium Moderate Liver
Resonance Loud Low Normal lung
Hyperresonance
Very loud Lower Emphysematouslung
Tympany Loud Higher Puffed out cheek, gastric airbubble
8/10/2019 Head to Toe Assessement
25/97
4.Auscultation:Process of listening for sounds over body cavities todetermine presence and quality of heart, lung, andbowel sounds.
8/10/2019 Head to Toe Assessement
26/97
TYPES OF AUSCULTATION
Direct auscultation: use of
unaided ear
Indirect auscultation:use ofstethoscope
8/10/2019 Head to Toe Assessement
27/97
PROCESS OF HEALTH
ASSESSMENT:
I. GENERAL APPEARANCE BEHAVIOR:
i) Gender and race:Certain illnesses are more likely toaffect the specific gender and race. Eg. Risk of havingskin cancer is 20% higher in whites than in blacks.
8/10/2019 Head to Toe Assessement
28/97
ii) Age: Age influences the normal physicalcharacteristics.
iii) Signs of distress: There may be obvious signs andsymptoms indicating pain, difficulty in breathing oranxiety.
8/10/2019 Head to Toe Assessement
29/97
iv) Body type: Trim, muscular, obese or excessively thin.
8/10/2019 Head to Toe Assessement
30/97
v) Posture: Observe whether the client has a slumped,erect or bent posture.
8/10/2019 Head to Toe Assessement
31/97
vi) Gait: Observe the walking pattern of the client. Notwhether the movements are coordinated oruncoordinated.
8/10/2019 Head to Toe Assessement
32/97
vii) Body movements: Note for any tremors involving theextremities.
viii) Hygiene and grooming: Note the appearance of hair,skin and finger nails. Also observe for the clothing.
ix)
Affect and mood:Affect is a persons feelings as they
appear to others.
x) Speech: An abnormal pace may be caused by emotions
and neurological impairments.xi) Substance abuse: Check for the history of substance
abuse.
8/10/2019 Head to Toe Assessement
33/97
VITAL SIGNS:
Equipment Needed:
A Stethoscope A Blood Pressure Cuff
A Watch Displaying Seconds
A Thermometer
8/10/2019 Head to Toe Assessement
34/97
1. Temperature:Temperature can be measured is several different ways:
Oral
Axillary
Aural
Rectal.
2. Respiration:
In adults, normal resting
respiratory rate is between
16-24 breaths/minute.
8/10/2019 Head to Toe Assessement
35/97
3. Pulse:
A normal adult heart rate is between 60 and 100beats per minute. A pulse greater than 100beats/minute is defined to be tachycardia. Pulse lessthan 60 beats/minute is defined to be bradycardia.
4. Blood Pressure:
Record the blood pressure as
systolic over diastolic
(Eg. "120/70" ).
8/10/2019 Head to Toe Assessement
36/97
HEIGHT, WEIGHT AND
CIRCUMFERENCE:
A persons general level of health can be reflected in
the ratio of height to weight. Weight is a routine measure during health visits.
A clients weight will normally vary daily because of
fluid loss or retention. Progressive weight gain is
` expected during pregnancy.
Head, chest and abdominalcircumference should be
assessed in case of infants.
8/10/2019 Head to Toe Assessement
37/97
PHYSICAL EXAMINATION:
8/10/2019 Head to Toe Assessement
38/97
Look
(Inspection)
Listen
(auscultation)
Feel
(palpation)
Tap(percussion)
Smell(olfaction)
SKILLS OF PHYSICAL EXAMINATION
8/10/2019 Head to Toe Assessement
39/97
8/10/2019 Head to Toe Assessement
40/97
Cynosis
Erythema
8/10/2019 Head to Toe Assessement
41/97
8/10/2019 Head to Toe Assessement
42/97
NORMAL NAIL SHAPE
Technique: view the index finger note the angle of
the nail base it should be above 160 degree.
8/10/2019 Head to Toe Assessement
43/97
ABNORMAL NAIL SHAPES
Early clubbing
Late clubbing
B
8/10/2019 Head to Toe Assessement
44/97
B. HEAD:
a. Eyes:Examine the conjunctiva,
sclera. Test pupils for irregularity,accommodation, and reaction.
Evaluate visual fields and visual
acuity.
8/10/2019 Head to Toe Assessement
45/97
Vision
Visual activity(ability to see small
detail): by snellens chart.
Peripheral vision:
8/10/2019 Head to Toe Assessement
46/97
b.
Ears:Examine the pinna and peri-auricular tissues. Testauditory acuity, perform Weber and Rinne tests.
8/10/2019 Head to Toe Assessement
47/97
EARS
Examination of ears: Pull the ears backward andupward.
Instrument used: Auto scope
External ears:Crusts, discharges, lesions etc.
Tympanic membrane: Normally it is shiny, translucent,with a pearl grey color. See for any perforation,lesions, bulging.
Hearing:There are 3 ways for testing the hearing.
8/10/2019 Head to Toe Assessement
48/97
Weber's test
It is used to assess the conductive
hearing loss.
Technique:Place a vibrating tuningfork in the midline of the persons
skull and ask if he can hear thesounds same in both the ears orbetter in one ear.
Result :
The person should hear the toneproduced by bone conductionequally in both ears, is the positivetest result
8/10/2019 Head to Toe Assessement
49/97
Rinne test
This is a test to compare the air conduction and thebone conduction sounds.Technique:
Place the stem of the vibrating tuning fork onpersons mastoid process and ask him or her to signalwhen the sound disappears note the time in
seconds. Invert the tuning fork so the vibrating end isnear the ear canal he should hear the sound.Note the time in seconds.Results : AC : BC = 2 : 1
8/10/2019 Head to Toe Assessement
50/97
c. Nose:Connect the nasal speculum to the otoscope and examine the nares,
noting the condition of the mucosa, septum and turbinate's.
d. Mouth:Examine the oral mucosa, the
tongue and teeth. Evaluate thefunction of cranial nerves IX, X,
and XII.
e. Face:Evaluation of symmetry, smile, frown, and jaw movement will provide
information about motor divisions of cranial nerves V and VII.
8/10/2019 Head to Toe Assessement
51/97
C.Neck:
Palpate the neck with emphasis on the salivary glands,lymph nodes, and thyroid. Look for tracheal deviation.Identify the carotid arteries and auscultate for bruits.
LYMPH NODES
8/10/2019 Head to Toe Assessement
52/97
Lymph nodes are assessed by palpating with the pad of the
finger for enlargement , tenderness and mobility . Normally nodes are not palpable. If palpable they should
be small, mobile, smooth and non tender.
8/10/2019 Head to Toe Assessement
53/97
Thyroid: palpation for size , symmetry ,tenderness and nodules.
8/10/2019 Head to Toe Assessement
54/97
Trachea: Palpation for alignment and position:
unequal space between trachea and sterno-cleidomastoid muscle on each side is abnormal, indicativeof trachea displacement.
8/10/2019 Head to Toe Assessement
55/97
CAROTID ARTERY :
Palpate one carotid
artery at a time justbelow the upperborder of the thyroid
cartilage.
RESPIRATORY ASSESSMENT
8/10/2019 Head to Toe Assessement
56/97
RESPIRATORY ASSESSMENT:
8/10/2019 Head to Toe Assessement
57/97
http://en.wikipedia.org/wiki/File:Ben_Fraser_pectus_carinatum.jpg8/10/2019 Head to Toe Assessement
58/97
Funnel chest (Pectus excavatum
describes an abnormal formationof the rib cage that gives the chest
a caved-in or sunken appearance.)
Pigeon chest (Pectus carinatum, isa deformity of the chestcharacterized by a protrusion
of the sternum and ribs.)
D
http://en.wikipedia.org/wiki/File:Ben_Fraser_pectus_carinatum.jpg8/10/2019 Head to Toe Assessement
59/97
D.CHEST AND LUNGS:
i) Inspection:
Observe the rate, rhythm, depth, and effort of breathing.
Listen for abnormal sounds such as wheezes.
Observe for retractions.
ii) Palpation:
Identify any areas of tenderness.
Assess expansion and symmetryof the chest.
Check for tactile fremitus.
8/10/2019 Head to Toe Assessement
60/97
iii) Percussion:
Percuss from side to side and top to bottom .
Categorize what you hear as normal, dull, or hyperresonant.
INTERPRETATION:Percussion Notes and Their Meaning:Flat or Dull Pleural Effusion or Lobar
Pneumonia
Normal Healthy Lung or Bronchitis
Hyper resonant Emphysema or Pneumothorax
8/10/2019 Head to Toe Assessement
61/97
8/10/2019 Head to Toe Assessement
62/97
iv) Auscultation:
Use the diaphragm of the stethoscope to auscultatebreath sounds. Note the location and quality of thesounds you hear.
A f A l i
:
8/10/2019 Head to Toe Assessement
63/97
Areas of Auscultation
8/10/2019 Head to Toe Assessement
64/97
ABNORMAL BREATH SOUNDS :
Crepts : fine, short interrupted sound heard duringinspiration and expiration. Example : Respiratory distress.
Rhonchi : low pitched continuous musical sound heard
during expiration and clears with coughing. Example :Pneumonia.
Wheeze : high pitched continuous musical sound heardduring inspiration or expiration and does not clear with
coughing. Example : Pneumonia .
Pleural friction Rub : grating type of sound heard duringinspiration and does not clear with coughing, example :
Empyema .
8/10/2019 Head to Toe Assessement
65/97
CARDIAC ASSESSMENT:
Inspection of the HeartThe chest wall and epigastrium is
inspected while the client is insupine position. Observe forpulsation and heaves or lifts.
Normal Findings:
There should be no lift or heaves.
8/10/2019 Head to Toe Assessement
66/97
PALPATION OF THE HEART
The entire pre-cordium (anterior surface of the body covering
the heart and lower thorax) is palpated methodically using thepalms and the fingers, beginning at the apex, moving to theleft sternal border , and then to the base of the heart.
NORMAL FINDINGS:
No, palpable pulsation over the
aortic, pulmonary, and mitral valves.
Apical pulsation can be felt on
palpation.
There should be no noted abnormal
heaves, and thrills felt over the apex.
Percussion of the Heart Th h i f i i f
8/10/2019 Head to Toe Assessement
67/97
The technique of percussion is oflimited value in cardiac assessment. It
can be used to determine borders ofcardiac dullness.
Auscultation of the Heart
Aortic valveRight 2ndintercostal
space (ICS) sternal border. Pulmonary ValveLeft 2ndICS sternal
border.
Mitral ValveLeft 5
th
ICSmidclavicular line.
Tricuspid Valve Left 5thICS sternalborder
8/10/2019 Head to Toe Assessement
68/97
AV Valves- Tricuspid and Mitral Semilunar valves- Pulmonicand aortic
8/10/2019 Head to Toe Assessement
69/97
Auscultating the heart
Auscultate the heart in all anatomic areas aortic, pulmonic, tricuspid andmitral.
Listen for the S1 and S2 sounds (S1 closure of AV valves; S2 closure ofsemi-lunar valve).
Listen for abnormal heart sounds e.g. S3, S4, and Murmurs.
Count heart rate at the apical pulse for one full minute.
Normal Findings:
S1 & S2 can be heard at all anatomic site.
No abnormal heart sounds is heard (e.g. Murmurs, S3 &S4).
Cardiac rate ranges from 60100 beats per min.
8/10/2019 Head to Toe Assessement
70/97
ABDOMINAL ASSESSMENT
E
8/10/2019 Head to Toe Assessement
71/97
E. ABDOMINAL ASSESSMENT:
Abdomen is divided into 4 main quadrants:
Right Upper Quadrant (RUQ) Right Lower Quadrant (RLQ)
Left Upper Quadrant (LUQ)
Left Lower Quadrant (LLQ)
8/10/2019 Head to Toe Assessement
72/97
8/10/2019 Head to Toe Assessement
73/97
i) Inspection:
Look for scars, striae, hernias, vascular changes, lesions, orrashes, movement associated with peristalsis or pulsations.
Note the abdominal contour. Is it flat, scaphoid, or
protuberant?ii) Auscultation:
Place the diaphragm lightly on the
abdomen, listen for bowel sounds. Listen for bruits over the renal
arteries, iliac arteries, and aorta.
8/10/2019 Head to Toe Assessement
74/97
iii) Percussion:
Percuss in all four quadrants using proper technique.
Categorize what you hear as tympanitic or dull.Tympany is normally present over most of theabdomen in the supine position. Unusual dullnessmay be a clue to an underlying abdominal mass.
8/10/2019 Head to Toe Assessement
75/97
Liver Span
Percuss downward from the chest in the right mid-clavicular line until you detect the top edge of liverdullness.
Percuss upward from the abdomen
in the same line until you detect the
bottom edge of liver dullness.
Measure the liver span between these
two points. This measurement should
be 6-12 cm in a normal adult.
8/10/2019 Head to Toe Assessement
76/97
8/10/2019 Head to Toe Assessement
77/97
vi) Palpation:
Palpation of the Liver
a Standard Method:
Place your fingers just below the
right costal margin and press firmly.
Ask the patient to take a deep breath.
You may feel the edge of the liver press against your
fingers. Or it may slide under your hand as the patientexhales. A normal liver is nottender.
8/10/2019 Head to Toe Assessement
78/97
b
Alternate Method:
This method is useful when the patient is obese orwhen the examiner is small compared to the patient.
Stand by the patient's chest.
"Hook" your fingers just below
the costal margin and press
firmly.
Ask the patient to take a deep breath.
You may feel the edge of the liver press against yourfingers.
8/10/2019 Head to Toe Assessement
79/97
GENITALIA AND RECTUM:Providing privacy
Not prolonging the examination
Warming instruments i.e. vaginal speculum
Using lubricants to minimize discomfort
Wear gloves during genital & rectal examination
Empty the bladder before examination
8/10/2019 Head to Toe Assessement
80/97
Male genitals Inspect the skin of glance penis. Observe for any
lesions, color, discharge or inflammation.
Assess secondary sex characteristics , observe the
penis and testes for size and shape, color, texture ofscrotal skin symmetry and the distribution of pubichair , position of meatus and circumcision.
Palpate the penis using your thumb and first two
fingers. Note any tenderness or nodules. Normally,testes feel firm and not hard with similarconsistency.
Female genitalia
8/10/2019 Head to Toe Assessement
81/97
Female genitalia
Female genitalia is examined by inspection andpalpation.
Inspect the external genitalia. Separate the labia and
inspect the labia minora, clitoris, urethral orifice andvaginal opening.
Observe for inflammation, discharge, ulceration,varicose veins, swelling and nodules.
In internal inspection, observe cervix for color,position, bleeding.
8/10/2019 Head to Toe Assessement
82/97
EXTREMITIES:
Upper and lower Extremities are assessed for size and
symmetry , various patterns , colour and texture ofskin and nail beds , hair distribution on hands , lowerlegs , feet and toes . Observe for pigmentation , rashes, scars , ulcers and edema.
8/10/2019 Head to Toe Assessement
83/97
HOMANS SIGN
Test for homans sign, an indicator of phlebitis in which
pain and soreness are present in the calf area when thefoot is dorsiflexed . The persons dorsiflexed leg issupported from calf with your non dominant hand . Noteany pain or soreness in the calf area. If present this would
be a positive homans sign ,indicating the possibility ofphlebitis .
MOTOR SYSTEM:
8/10/2019 Head to Toe Assessement
84/97
MOTOR SYSTEM:
Inspect the voluntary muscles for atrophy,fasciculation (uncontrollable twitching)andinvoluntary movements. In addition assess gait ,
Romberg's sign for muscle strength andcoordination.
Gait: is a persons style of walking. To assess gait,instruct the person to walk across the room, turn and
walk back towards you . Observe the persons balanceand posture . Ataxia is an uncoordinated gait thatresult from cerebellar disease or intoxication.
8/10/2019 Head to Toe Assessement
85/97
Rombergs test : Rombergs test is a test of sensory equilibrium.Instruct the person to stand with the feet together and eyesopen . Note the persons balance . Then have the person closethe eyes. Normally you will observe only minimal swaying . Apositive test will suggest cerebellar ataxia.
8/10/2019 Head to Toe Assessement
86/97
REFLEXES OF MUSCLES:
Tests of muscle strength andassessment of common reflexes
Type Procedure Normal
reflex
8/10/2019 Head to Toe Assessement
87/97
Deep
tendon
reflexes
Biceps Flex the clients arm at elbow withpalms down. Place your thumb inantecubital fossa at the base ofbiceps tendon . Strike the thumbwith the reflex hammer .
Flexion ofarm atelbow.
Triceps Flex the clients elbow , holding armacross the chest , or hold the upperarm horizontally and allow thelower arm to go limp. Strike tricepstendon just above the elbow .
Extensionat elbow.
Patellar Make the client sit with legs hangingfreely over the side of the bed orchair or have the client lie supineand support knee in a flexed
position . Briskly tap patellar tendon
Extensionof lower legat knee.
Procedures Normal
reflex
http://www.google.co.in/imgres?imgurl=http://www.waybuilder.net/sweethaven/MedTech/Neurology/fig0207.jpg&imgrefurl=http://www.waybuilder.net/sweethaven/MedTech/Neurology/Neurology01.asp?mode=1&iNum=0204&usg=__Kdu1Sozlm_MNbkm-px0kaDGnOrM=&h=304&w=314&sz=31&hl=en&start=6&zoom=1&tbnid=TNqidHYstCMtoM:&tbnh=113&tbnw=117&ei=lOxxTe_jAYrOrQfX-c3SCg&prev=/images?q=Deep+tendon+reflexes(biceps)&um=1&hl=en&sa=N&tbs=isch:1&um=1&itbs=18/10/2019 Head to Toe Assessement
88/97
Achilles Make the client assume the same
position as for patellar reflex. Slightlydorsiflex the clients ankle by graspingtoes in the palm of your hand . Strikeachilles tendon just above the heel.
Plantar
flexion offoot .
Babinskis
Have the client lie supine with legsstraight and feet relaxed . Take thehandle end of the reflex hammer andstroke lateral aspect of the sole fromthe heel to the ball of the foot , curvingacross the ball of the foot toward thebig toe.
Bending oftoedownwards.
Maneuvers to assess muscle strength:
http://www.google.co.in/imgres?imgurl=http://farm3.static.flickr.com/2148/2052063648_b462f8da14.jpg&imgrefurl=http://www.flickr.com/photos/automatt/2052063648/&usg=__C4Kg2isF8OB9_0IrHSxTCL2Ypps=&h=458&w=500&sz=101&hl=en&start=6&zoom=1&tbnid=WjZOHw6DZK5_BM:&tbnh=119&tbnw=130&ei=Mu5xTfS2B5HRrQeXg6TTCg&prev=/images?q=(Babinski+)&um=1&hl=en&sa=N&tbs=isch:1&um=1&itbs=18/10/2019 Head to Toe Assessement
89/97
Muscle group Maneuver
Neck Place your hand firmly against the clients upper jaw .ask the
client to turn head laterally against resistance.
Shoulder Place your hand over the midline of the clients shoulder ,exerting firm pressure . Have the client raise shoulder againstresistance.
Elbow,Biceps,Triceps.
Pull down the forearm as the client attempts to flex the arm. Asthe clients arm is flexed ,apply pressure against the forearm
.ask the client to straighten his/her arm.
Hip ,Quadriceps
When the client is sitting apply downward pressure to thigh .Ask the client to raise his leg up from the table.The client sits, holding shin of the flexed leg . Ask him tostraighten his leg against the resistance.
MUSCLE STRENGTH
8/10/2019 Head to Toe Assessement
90/97
To grade or quantify muscle strength, assess the patient asfollow:
Grade
Description
0/5 No muscle movement
1/5 Visible muscle movement, but no movement at the joint
2/5 Movement at the joint, but not against gravity
3/5 Movement against gravity, but not against added resistance
4/5 Movement against resistance, but less than normal
5/5 Normal strength
SENSORY SYSTEM:
8/10/2019 Head to Toe Assessement
91/97
Light touch/ superficial pain: Using a wisp of cottonand a safety pin alternatively , touch the distal andproximal portions of the upper and lowerextremities.
The temperature test can be done by asking thepatient to touch and identify the hot and cold testtube filled with hot and cold water respectively.
Vibrationis assessed by tapping a tuning fork and
placing it firmly on a persons inter-phallengial jointof the finger and great toe. Ask the patient todescribe the sensation and to identify when thesensation ends.
8/10/2019 Head to Toe Assessement
92/97
Two point discrimination: When assessing two pointdiscrimination , touch the person alternatively withone or two safety pins on a particular body part,
such as the finger pads . ask the patient if one or twosensations are felt.
Point localizationis assessed by touching variousparts of the persons body with a wisp of cotton. The
person is instructed to open the eyes after having feltthe touch and point to the area.
8/10/2019 Head to Toe Assessement
93/97
8/10/2019 Head to Toe Assessement
94/97
CONSCIOUSNESS
Assessment of consciousness begins with notingwhether the client is awake and alert . If the person
has altered the level of consciousness , assess whetherthe person is demonstrating stupor or coma . Glasgowcoma scale to be maintained for the patient withaltered sensorium and in that three points are
observed: eye open response, verbal response andmotor response .
AFTER CARE:
8/10/2019 Head to Toe Assessement
95/97
When the physical examination is over, remove thedrape & help the person to put on cloths. Be sure thepatient is safe and comfortable.
DISMANTLING OF ARTICLES:
Articles should be sent for sterilization. Disposablearticles should be immediately disposed off andreplacement of all the articles should be done to thearea specified.
POINTS TO BE REMEMBER:
8/10/2019 Head to Toe Assessement
96/97
Ensure that adequate privacy is provided during theobservation.
Always take help in case of pediatric /unconsciouspatient / uncooperative patient .
Ensure adequate light.
Inform the patient / relatives before
and after the physical examination .
Record all the observations and
preserve in safe custody . Inform any abnormal findings
to senior nurse/doctor.
8/10/2019 Head to Toe Assessement
97/97