PHYSICAL PHYSICAL EXAMINATIONEXAMINATION

Midterm Midterm Systems Systems

requirements requirements assessment assessment

-critical elements-critical elements -used on -used on care plan care plan

-includes systems -includes systems -used in hosp.-used in hosp.

CRITICAL ELEMENTSCRITICAL ELEMENTS

Wash hands and gather equipmentWash hands and gather equipment Prepare assessment areaPrepare assessment area Introduce yourself and state purposeIntroduce yourself and state purpose Observe general appearanceObserve general appearance Measure height and weightMeasure height and weight

NEUROLOGICAL SYSTEMNEUROLOGICAL SYSTEM

LOCLOC OrientationOrientation PERRLAPERRLA

((PPupils upils EEqual qual RRound ound RReactive to eactive to LLight ight and and AAccommodation)ccommodation)

Sensation (light touch/temperature)Sensation (light touch/temperature)

Light touchLight touch

CARDIOVASCULAR SYSTEMCARDIOVASCULAR SYSTEM

Listen at Listen at

4 sites4 sites Take Take

apical pulseapical pulse

(note rhythm(note rhythm

/murmur)/murmur) S1, S2S1, S2

Assess pulsesAssess pulses

Assess for edemaAssess for edema

Assess for Homan’s sign

NailbedsNailbeds

ColorColor Cap refillCap refill

(UE/LE)(UE/LE)

RESPIRATORY SYSTEMRESPIRATORY SYSTEM

Assess rate/depth rhythmAssess rate/depth rhythm Assess lung soundsAssess lung sounds

10 sites anterior/ 9 sites posterior10 sites anterior/ 9 sites posterior

Anterior sitesAnterior sites

Posterior sitesPosterior sites

GASTROINTESTINAL SYSTEMGASTROINTESTINAL SYSTEM

Abd contourAbd contour

Bowel soundsBowel sounds MassesMasses BowelBowel

movementmovement

Genitourinary SystemGenitourinary System

Bladder distentionBladder distention

Musculoskeletal SystemMusculoskeletal System

GaitGait Bilateral hand gripBilateral hand grip Bilateral hand strengthBilateral hand strength ROM (UE and LE)ROM (UE and LE)

Integumentary SystemIntegumentary System

ColorColor TextureTexture TurgorTurgor TemperatureTemperature MoistureMoisture AbnormalitiesAbnormalities