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    HEALTH

    ASSESSMENT

    HEAD TO TOE PHYSICAL

    EXAMINATION

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    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.

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    HEALTH

    HISTORY

    PHYSICAL

    ASSESSMENT

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    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.

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    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

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    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.

    .

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    PREPARATIONS

    Comfort

    Position,gowning

    Height of

    examinationtable

    Lightsources

    Eliminatedistractions

    Equipments:clean & inworking

    condition

    http://www.casualtysimulation.com/gallery/d/989-2/physical_assessment_kit
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    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_kit
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    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_kit
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    POSITIONS OF PATIENT

    2. PRONE POSITION:

    1. SUPINE POSITION:

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    3. SITTING POSITION:

    4. SEMI FOWLERs POSITION:

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    5. SIMs POSITION:

    6. KNEE-CHEST POSITION:

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    7. DORSAL RECUMBENT POSITION:

    8. LITHOTOMY POSITION:

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    9. TRENDELENBERGs POSITION:

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    METHODS OF EXAMINING:

    1. Inspection:

    A method of systematic observation. Inspectionshould begin with general observation of the patientprogressing to specific body areas.

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    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.

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    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

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    For light palpation, press the skin gently with the tips oftwo or three fingers held close together.

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    3. Percussion:Tapping of the body lightly but sharply to determineconsistency of tissues and/or organs through

    vibration `& areas of tenderness.

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    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.

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    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

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    4.Auscultation:Process of listening for sounds over body cavities todetermine presence and quality of heart, lung, andbowel sounds.

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    TYPES OF AUSCULTATION

    Direct auscultation: use of

    unaided ear

    Indirect auscultation:use ofstethoscope

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    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.

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    ii) Age: Age influences the normal physicalcharacteristics.

    iii) Signs of distress: There may be obvious signs andsymptoms indicating pain, difficulty in breathing oranxiety.

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    iv) Body type: Trim, muscular, obese or excessively thin.

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    v) Posture: Observe whether the client has a slumped,erect or bent posture.

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    vi) Gait: Observe the walking pattern of the client. Notwhether the movements are coordinated oruncoordinated.

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    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.

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    VITAL SIGNS:

    Equipment Needed:

    A Stethoscope A Blood Pressure Cuff

    A Watch Displaying Seconds

    A Thermometer

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    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.

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    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" ).

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    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.

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    PHYSICAL EXAMINATION:

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    Look

    (Inspection)

    Listen

    (auscultation)

    Feel

    (palpation)

    Tap(percussion)

    Smell(olfaction)

    SKILLS OF PHYSICAL EXAMINATION

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    Cynosis

    Erythema

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    NORMAL NAIL SHAPE

    Technique: view the index finger note the angle of

    the nail base it should be above 160 degree.

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    ABNORMAL NAIL SHAPES

    Early clubbing

    Late clubbing

    B

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    B. HEAD:

    a. Eyes:Examine the conjunctiva,

    sclera. Test pupils for irregularity,accommodation, and reaction.

    Evaluate visual fields and visual

    acuity.

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    Vision

    Visual activity(ability to see small

    detail): by snellens chart.

    Peripheral vision:

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    b.

    Ears:Examine the pinna and peri-auricular tissues. Testauditory acuity, perform Weber and Rinne tests.

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    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.

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    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

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    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

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    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.

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    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

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    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.

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    Thyroid: palpation for size , symmetry ,tenderness and nodules.

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    Trachea: Palpation for alignment and position:

    unequal space between trachea and sterno-cleidomastoid muscle on each side is abnormal, indicativeof trachea displacement.

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    CAROTID ARTERY :

    Palpate one carotid

    artery at a time justbelow the upperborder of the thyroid

    cartilage.

    RESPIRATORY ASSESSMENT

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    RESPIRATORY ASSESSMENT:

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    http://en.wikipedia.org/wiki/File:Ben_Fraser_pectus_carinatum.jpg
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    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.jpg
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    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.

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    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

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    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

    :

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    Areas of Auscultation

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    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 .

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    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.

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    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

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    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

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    AV Valves- Tricuspid and Mitral Semilunar valves- Pulmonicand aortic

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    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.

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    ABDOMINAL ASSESSMENT

    E

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    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)

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    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.

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    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.

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    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.

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    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.

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    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.

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    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

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    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

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    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.

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    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.

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    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:

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    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.

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    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.

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    REFLEXES OF MUSCLES:

    Tests of muscle strength andassessment of common reflexes

    Type Procedure Normal

    reflex

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    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

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    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:

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    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

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    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:

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    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.

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    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.

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    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:

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    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:

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    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.

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