TYPES OF ASSESSMENT

Complete Assessment
• Typically includes a thorough health history and
comprehensive head-to-toe physical exam

Problem Focused Assessment

•assessment based on specific functioning of the organ
 Pre-requisites for head to assessment:
• Assemble all necessary equipment and Perform hand hygiene
•Check room for temperature
•Introduce yourself to patient.
•Explain process to patient.
•Be organized and systematic in your assessment.
•Use appropriate listening and questioning skills.
•Ensure patient’s privacy and dignity.
•Complete necessary focused assessments.
•Document immediately after assessment
 EQUIPMENT CHECKLIST:
• Gloves
• Thermometer
• BP Apparatus
• Watch
• Weighing Scale
• Tape measure, and Stethoscope.
• SNELLEN Chart
• Documentation Booklet.
 Physical examination

GENERAL ANTHROPOMETRIC
APPEARANCE MEASUREMENTS
• Height
• Level of
Consciousness • Weight
• Hygiene
• BMI
• Body Build
• Abdominal
• Mobility and speech circumference (if
• Any notable needed)
deformities
 Physical examination

VITAL SIGNS HEAD

• Temperature • Size and shape

• Pulse • Hair and scalp
• Respiration • History of head injury
• BP
• Pain
 Physical examination

ENT ENT

• Inspect lips, mouth,

• Visual acuity using
tongue, and teeth , &
SNELLEN chart,
dentures
PERLA, Conjunctiva &
• Assess swallowing, thyroid
Sclera
gland enlargement
• Nasal septum, Bilateral
air entry, nasal • Discharge or bleed from
obstruction any of the orifice
 Physical examination

UPPER EXTREMITIES LOWER EXTREMITIES

• Skin
• Skin
• Toe Nails
• Nails
• Pedal pulse
• Radial pulse
• Edema
• Capillary refill
• ROM
• ROM
• Muscle tone and strength
• Muscle tone and
strength
.
BACK AREA
Turn patient to side or ask to
sit up or lean forward

•Inspect back and spine.

Inspect coccyx/buttocks
(Pressure points especially)
 SYSTEMIC examination
INSPECT: AUSCULTATE:

• Expansion/retraction • For breath sounds

of chest wall/work of anteriorly and
breathing and/or posteriorly
accessory muscle use • Apices and bases for
• Jugular distension any adventitious
sounds
• Apical heart rate

•PALPATE:

•For symmetrical lung

expansion
 UNUSUAL FINDINGS:

• Asymmetrical chest expansions may indicate conditions such as atelectasis,

pneumonia, fractured ribs, or pneumothorax.
• Use of accessory muscles may indicate acute airway obstruction or massive
atelectasis.
• Jugular distension of more than 3 cm above the sternal angle while the
patient is at 45º may indicate cardiac failure.
• The presence of crackles or wheezing must be further assessed, documented,
and reported.
 ABDOMEN
INSPECT:

Abdomen for distension,

asymmetry

PALPATE:

All quadrants for pain and

bladder/bowel distension
(light palpation only) AUSCULTATE:
Bowel Sounds
Determine frequency and
type of bowel movements.
 UNUSUAL FINDINGS:

• Abdominal distension may indicate ascites associated with conditions such

as heart failure, cirrhosis, and pancreatitis.
• Markedly visible peristalsis with abdominal distension may indicate
intestinal obstruction.
• Hyperactive bowel sounds may indicate bowel obstruction, gastroenteritis,
or subsiding paralytic ileum.
• Hypoactive or absent bowel sounds may be present after abdominal surgery,
or with peritonitis or paralytic ileus.
• Pain and tenderness may indicate underlying inflammatory conditions such
as peritonitis.
 GENITO-URINARY

PALPATE

• Deep palpation
to identify
renomegaly

Check urine output

for frequency, color,
odor.
 UNUSUAL FINDINGS:

• Unusual findings in urine output may indicate compromised urinary

function.

• Hematuria may indicate renal stones, infection

Miscellaneous:

• Check for other Tubes, drains, dressings, and IVs:

• Inspect for drainage, position, and function.
• Assess wounds for unusual drainage.
• Check if full or partial weight-bearing.
• Determine gait/balance.
• Determine need for and use of assistive devices.