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Health Assessment and Documentation

Physical Exam
Physical examination is a critical element of
any occupational health practice. A quality
physical examination program provides a
database for:
health surveillance
risk exposure
and disease prevention
PE Considerations
Physical examinations are
usually based on the specic
needs of the employer.
Ideally, the physical
examination is based on:
company policy
job analysis, and
signed protocols
Align an employees physical and emotional capabilities
with current job demands
Provide baseline health status data for future
Identify any pre-existing or concurrent health related
Evaluate working conditions that may have an effect on
workers health and safety
Fulll legally mandated requirements
Health screening
examinations can be
conducted with direct
referral to a physician or
other health care
provider for follow up as
It is important to
understand the Nurse
Practice Act(s) and verify
the scope of practice.
Common Examinations Associated
with Occupational Health Services
1. Post-offer examination
2. Periodic examination
3. Job transfer examination
4. Termination examination
5. Medical/health surveillance
6. Certied Drivers Physical Exam
7. Hazardous material examination
8. Flight/military physical examination
9. Return to work examination
10.Fitness for duty examination
Assessment Skills
Inspection - visual examination, general state
of health, apparent age, physique
Palpation - use of touch/feel, maybe difcult
at rst due to cultural beliefs and biases,
warmth, caring, understanding
Percussion - gentle beating using both hands,
detects uids, air or mass
Auscultation - quality of sounds, intensity,
duration of heart, lungs and intestines.
System Flow
The Lungs
Inspection (respiration), palpation,
percussion, auscultation
The Heart Inspection (BP, P), palpation, auscultation
The Abs
Inspection, Auscultation, Percussion,
The Musculoskeletal
Inspection, Palpation, ROM, Strength
testing, Deep tendon reexes
Vital Signs
Temperature _____
Pulse Rate _____
Respiratory Rate _____
Blood Pressure _____
Pain Assessment _____
Oxygen Saturation _____
Lung Problems ___________Stomach Problem_____________
Thyroid Problems _________Neurological Problems_________
Heart Problems __________Liver Problems _______________
Vision Problems __________Kidney Problems _____________
Arthritis _________________Diabetes ___________________
Chronic infection __________Treatment: __________________
Cancer (where/type) _______Treatment: _________________
Other Past Medical History or Surgeries:
! Heart disease
! Hypertension
! Diabetes
! Stroke
! Seizures
! Kidney disease
! Liver disease
! Lives alone
! Lives with _________________

! Stairs at home Yes ___ No___
! Sleep pattern _______________
! Immunizations current?
! Yes ______
! No ______
! Last Tetanus toxoid? _______
! Hepatitis A _______
! Hepatitis B _______
! Flu Vaccine ______

Nicotine Use:
! No
! Yes How much? _______ How Long? _____________
! Instructed on No Smoking Policy? Yes No
! Do you live in a smoking environment? Yes No
Alcohol Use:
! No
! Yes How much? _______How Long? _____________
! Last Drink? ______________________________________
Social Drug Use:
! No
! Yes Type?_______________ Frequency?__________

Impaired hearing
! Hearing Aid
Impaired vision
! Glasses
Cane or walking device
Other: ______________

Diet restriction:
Special diet:
Systems Review
! Cooperative Yes No
! Memory Changes Yes No
! Dizziness Yes No
! Headaches Yes No
! Oriented to: Person __ Place __ Time __
! Deviation: ________________Pupils Size: __________________
! Reaction: Brisk __ Sluggish __ No Response __
! LOC: Alert __ Confused __ Sedated __ Somnolent __
Comatose Agitated __ Other ___
! Speech: Clear __ Slurred __ Aphasic __ Dysphasia __ None
! Grips: ________Foot pushes: _________Gag reflex:
Pulmonary Assessment
Normal Breath Sounds
Tracheal sounds
Bronchial sounds
Bronchovesicular sounds
Vesicular sounds

Abnormal Breath Sounds
Wheezes - hissing sound or shrill quality
Crackles - ne crackles and course crackles
Friction rub - creaking and grating sounds
associated with respiratory movements from
inamed pleural space
Mediastinal crunch - a series of precordial
crackles synchronous with the heart beat and
best heard in lateral position
Cardiac Assessment
Pulse Classication in Adults
Normal Bradycardia Tachycardia
60 to 100 bpm less than 60 bpm more than 100 bpm
Regular Regularly Irregular Irregularly Irregular
Evenly spaced beats,
may vary slightly
with respiration
Regular pattern
overall with
skipped beats
Chaotic, no real
pattern, very
difcult to measure
rate accurately
Skin/Extremities and
Physical Findings
Describe and graph all abnormalities by number:
1. Bruises
2. Incisions
3. Lacerations
4. Rashes
5. Decubitus
6. Dryness
7. Scars
8. Lesions
9. Abnormal color
11.Body piercing
12.Skin tear
Abdominal Assessment
General appearance
Respiratory Rate (shallow/increased in
patients with abdominal pain)

Jaundice: hyperbilirubinemia

Spider angiomas: alcoholic

cirrhosis, pregnancy
General percussion
CVA tenderness
Shifting dullness or ascites
Fluid wave for ascites

Diffuse rigidity - peritonitis

Localized rigidity - appendix, gallbladder

Hyperesthesia - peritonitis

Masses, pain, guarding

Rebound tenderness

Peritoneal irritation (appendicitis)

Some HPI questions to consider
Onset and duration

sudden, gradual, persistent, intermittent


dull, sharp, burning, stabbing, aching


radiation, supercial, deep, changing

Associated symptoms

nausea/vomiting/diarrhea, change in abdominal

girth, belching
Genito-Urinary System
Breast Self Exam
Testicular Self Examination
Group Work
Write down what you saw in the picture.
Nursing Documentation
Group 1
Group 2
Thank you!