PHYSICAL EXAMINATION

Midterm Systems Midterm Systems requirements assessment -critical elements-used on care plan -critical elements-used on care plan -includes systems -used in hosp.

CRITICAL ELEMENTS Wash hands and gather equipment Wash hands and gather equipment Prepare assessment area Prepare assessment area Introduce yourself and state purpose Introduce yourself and state purpose Observe general appearance Observe general appearance Measure height and weight Measure height and weight

NEUROLOGICAL SYSTEM LOC LOC Orientation Orientation PERRLA PERRLA (Pupils Equal Round Reactive to Light and Accommodation) (Pupils Equal Round Reactive to Light and Accommodation) Sensation (light touch/temperature) Sensation (light touch/temperature)

Light touch

CARDIOVASCULAR SYSTEM

Listen at Listen at 4 sites Take Take apical pulse (note rhythm /murmur) S1, S2 S1, S2

Assess pulses Assess pulses

Assess for edema Assess for Homan’s sign

Nailbeds Color Color Cap refill Cap refill(UE/LE)

RESPIRATORY SYSTEM Assess rate/depth rhythm Assess rate/depth rhythm Assess lung sounds Assess lung sounds 10 sites anterior/ 9 sites posterior 10 sites anterior/ 9 sites posterior

Anterior sites

Posterior sites

GASTROINTESTINAL SYSTEM Abd contour Abd contour

Bowel sounds Bowel sounds Masses Masses Bowel Bowelmovement

Genitourinary System Bladder distention Bladder distention

Musculoskeletal System Gait Gait Bilateral hand grip Bilateral hand grip Bilateral hand strength Bilateral hand strength ROM (UE and LE) ROM (UE and LE)

Integumentary System Color Color Texture Texture Turgor Turgor Temperature Temperature Moisture Moisture Abnormalities Abnormalities