rle

• Components of physical assessment - general survey

  • Level of Consciousness and Orientation
  • Language and Communication
  • Physical deformities and signs of illness
  • Behavioural Status
  • Physical Appearance
  • Posture, Symmetry and Gait
• Level of Consciousness

  The degree of awareness of environmental stimuli, varies from full wakefulness and alertness to coma
• Glasgow Coma Scale (GCS)

  Assessment tool for level of consciousness
• GCS Scoring

  • 14 - 15 - perfectly normal
  • 13 - 10 - lethargic
  • 8 - 9 - stuporous
  • 7 and below - coma
• Alert

  Awake, readily aroused, fully aware of internal and external environment, conducts meaningful interpersonal conversation
• Lethargic

  Drifts off to sleep when not stimulated, aroused when name is called but looks drowsy, responds to question but thinking seems to be slow
• Obtunded

  Sleeps most of the time, difficult to arouse, needs a loud shout or vigorous shake, speech mumbled
• Semi Coma / Stupor

  Spontaneously unconscious, responds only to spontaneous vigorous shake, can only groan, mumble or move restlessly, reflex activity still persists
• Coma

  Completely unconscious, no response to pain, some reflex activity but no purposeful activity
• Assessing level of consciousness

  Assess the client's level of consciousness
• Normal level of consciousness

  • Fully awake and alert, eyes are open and follow people or objects, attentive to questions and responds promptly and accurately to commands, if sleeping, responds readily to verbal or physical stimuli and demonstrates wakefulness and alertness
• Abnormal level of consciousness

  • Has lowered level of consciousness and shows irritability, short attention span, or dulled perceptions, may respond to physical stimuli only, the lowest extreme is coma, when the eyes are closed and the client fails to respond to verbal or physical stimuli, when no voluntary movement
• Assessing orientation

  Assess client's orientation, ask the client to state his/her own name, current location, and approximate day, month, or year
• Normal orientation

  • Aware of who he/she is (orientation to person), where he/she is (orientation to place), and when it is (orientation to time)
• Abnormal orientation

  • Unable to follow simple commands or answer simple questions
• Assessing language and communication

  Assess appropriateness of client's responses, describe quantity of speech (amount and pace), listen for the relevance and organization of thoughts
• Normal language and communication

  • Responds appropriately to commands, repeats and remembers information, uses appropriate native language, smooth, normal paced manner of speaking, exhibits relevance and organization of thoughts
• Abnormal language and communication

  • Confused, has inappropriate responses, dysphasia, dysarthria, memory loss, hallucinations, not clear/not smooth/inappropriate contents
• Assessing physical deformities and signs of illness

  Observe for obvious signs of health or illness

  
• Normal physical appearance

  • No signs of illness, no physical deformities
• Abnormal physical appearance

  • Shows labored breathing, wheezing, coughing, wincing, sweating, guarding of body part (suggests pain), anxious facial expression, fidgety movements
• Assessing behavioural status

  Describe client's affect and mood, assess the client's attitude, describe over-all hygiene and grooming
• Normal behavioural status


  • Eyes are alert and in contact, relaxed, smiles or frowns appropriately, comfortable, cooperative and has a calm demeanor, clothing reflects gender, age, climate and is appropriate for the occasion, hair, skin, and clothing are clean, well-groomed
• Abnormal behavioural status


  • Eyes are closed or averted, no eye contact, the client is frowning or grimacing, does not cooperate, and does not answer questions, wears unusual clothing for gender, age, climate and occasion, hair is poor groomed, lack of cleanliness, excessive oil on the skin, body odor is present
• Assessing physical appearance


  Describe physical appearance, describe body built, measure height, measure weight, determine BMI
• Normal physical appearance

  • Person appears his or her stated age, proportionate body built (Ectomorph, Mesomorph, Endomorph), height appears within normal range for age and genetic heritage, weight appears within normal range for height and body build, body fat distribution is even
• Abnormal physical appearance

  • Person does not appears his or her stated age, extremities not proportionate to the torso, excessively tall or short, dwarfism, gigantism, uneven fat distribution
• Endomorph

  A pear shaped body, a rounded head, wide hips and shoulders, wider front to back rather than side to side, a lot of fat on the body, upper arms and thighs
• Mesomorph

  A wedge shaped body, a cubical head, wide broad shoulders, muscled arms and legs, narrow hips, narrow from front to back rather than side to side, a minimum amount of fat
• Ectomorph

  A high forehead, receding chin, narrow shoulders and hips, a narrow chest and abdomen, thin arms and legs, little muscle and fat
• Body Mass Index (BMI)

  Practical measure for estimating total body fat, calculated as weight in kilograms and divided by the square height in meters
• Normal BMI range

  • Male: 20.7 - 26.4, Female: 19.1 - 25.8
• Abnormal BMI range

  • Client has lowered level of consciousness and shows irritability, short attention span, or dulled perceptions
• Assessing posture, symmetry, and gait

  Describe posture and gait, observe client while standing, sitting and walking
• Normal posture, symmetry, and gait

  • Posture is upright, stands comfortably erect as appropriate for age, body parts look equal bilaterally and are relative in proportion to each other, base is wide as shoulder width, foot placement accurate, walk is smooth, even, and well balanced, (+) of symmetric arm swing
• Abnormal posture, symmetry, and gait

  • Rigid spine and neck, moves as one unit, stiff and tense, ready to spring from chair, fidgety movements, scoliosis, kyphosis, lordosis, unilateral atrophy or hypertrophy, asymmetric location of body part, walks with a limp, waddles, drags foot, limb movements are uneven or unilateral
• Components of integumentary assessment

  • Skin
  • Hair
  • Nails
• Assessing skin

  Inspect for skin color uniformity, inspect for lesions according to locations, distribution, color, configuration, size, shape, type or structure

  
• Normal skin

  • Varies from light to deep brown, ruddy pink to light pink, yellow overtones to olive, generally uniform pigmentation except in areas exposed to the sun, areas of lighter pigmentation (palms, lips, nail beds) in dark-skinned people, absence of bruising/bleeding on the skin, freckles, some birthmarks, some flat and raised nevi, no abrasions and other lesions

  
• Abnormal skin

  • Pallor, jaundice, cyanosis, erythema, areas of either hyperpigmentation or hypopigmentation (Vitiligo, Albinism), ecchymosis, petechiae, primary and secondary lesions