ASSESSMENT

Gather Equipment/Provide Privacy/Ensure Proper Lightening
Wash Hands
Ensure visualization of each body part as its examined
Introduce self to patient (my name is….. how are you doing today)
General Survey
Say all of this…
Can you state your age for me? Client appears to be stated age.
LOC-Ask client: Can you tell me you name please, DOB, and where are you today, what month and year. Client is alert and oriented x3 -- to person, place, time
Client’s skin color appears like pink and evenly pigmented without lesions or redness
Client nutritional status appears appropriate for weight, height and body size.
Client is sitting upright and appears to be relaxed and comfortable
Clients body parts are intact and appear equal without no obvious physical deformities.
Client is cooperative and smiling, expresses her feelings appropriate to the situation.
Client’s speech is in a moderate tone, clear, and culturally appropriate.
Upon general observation clients hearing is intact, she hasn’t asked me to repeat anything.
Clients dress is appropriate to the season and client is cleaned and well groomed
Ask her to walk a few feet and then walk back… State “ Gait is rhythmic and coordinated, with arms swinging at side., walk is smooth and well balanced”

Posterior Lungs – stand behind client
State out all parts as you inspect.
Inspect rhythm, depth and pattern of breathing. State I’m going to inspect respirations for depth, rhythm, and pattern. Client’s respirations are relaxed, effortless, and quiet. They are of a regular rhythm and normal depth.
Palpate for symmetric chest expansion by placing hands at the T9 vertebra. As client inhales your hands should expand 5-10cm apart. State Ask client to take a deep breath… and say “Client has symmetric chest expansion bilaterally”

Auscultate systematically for breath sounds. At each position have client inhale and exhale and also tell them to breathe deeply through their mouth. State “Vesicular breath sounds present and No adventitious sounds heard”

Anterior Chest, Lungs, and Heart
State all parts as you inspect them.
Inspect the skin, musculoskeletal development, and symmetry. Have the client lay down and inspect the skin. State “I am going to inspect the clients skin, musculoskeletal development and symmetry, Client’s skin is light pink evenly pigmented without lesions or redness. Sternum is positioned at midline and thorax expands symmetrically”.

Inspect respirations: Respiratory effort and use of accessory muscles., pulsations or heaving. Stand in front of patient and tell them that you are just going to watch them. State “I will now inspect my clients respirations State: Respirations are relaxed, effortless and quiet. The client does not use accessory muscles to assist breathing, no pulsations or heaving is observed.

Palpate the chest wall for stability, crepitation, and tenderness. State “I am going to palpate her chest wall. Tell me if you feel any tenderness. Client is stable, no tenderness or crepitation palpated”.

Palpate precordium for thrills, heaves, pulsations. Start by putting hand below breast at apex then between breast. State: No thrills, heaves, or pulsation felt. Auscultate systematically for breath sounds, at least 4. State “I am going to auscultate for breath sounds. (Ask client to take deep breaths through the mouth.) . Client has clear even vesicular breath sounds. No adventitious sounds are heard”. Auscultate the apical pulse rate and rhythm for a full minute. Should be 60-100 beats per minute. State “I am going to listen to the apical pulse. Client has an apical pulse of ……, and a regular rhythm is present.

Auscultate systematically the aortic, pulmonic S2, Erb’s point, tricuspid and mitral S1 areas. Have Client sitting and do this with diaphragm and then bell, have client supine do with diaphragm and then bell . Do twice each. One time with regular and other time with bell. Laying left lateral with bell only to ausculate for murmur. State “I am going to auscultate the aotic, pulmonic, Erb’s point, and mitral areas, (auscultate), with diaphragm and then with the bell all 4 areas are heard with S1 in the mitral and S2 in the Pulmonic being the loudest areas S3 and S4 murmurs not heard”

1st Section you can draw
Head and Face
State all parts as you inspect
Equipment needed for this section: pen light, qtip, tongue depressor,
Inspect the skin. State “I am going to inspect the skin, (look over the skin on client’s face and head), the skin is light pink and evenly pigmented no obvious lesions or redness”

Inspect symmetry and external characteristics of head and face. State “Face is oval and symmetric. No abnormal movements, Head is symmetric and in midline with the body, and is appropriate in size related to body size”.

Inspect client’s facial movements for cranial nerve 5 & 7. State “I am going to inspect facial movements ask client to clench teeth, smile, puff out cheeks, wrinkle forehead, squeeze eyes tighly shut, tick out tongue. Clients cranial nerves 5 & 7 is intact”.

Inspect and palpate scalp and hair for texture, distribution, and quantity of hair. Run hands symmetrically through client’s hair to palpate the scalp, starting at the hairline stopping in the occipital area. State “Clients head is hard and smooth without lesions, scalp is clean and dry, hair is thick and shiny and evenly distributed, blonde in color”

Percuss the frontal and maxillary sinuses Page: 361 tap with double fingers. State “Frontal and maxillary sinuses are not tender on percussion”

Eyes
External Examination
State all parts as you inspect.
Inspect eyelids, eyelashes, brows. State “I am going to inspect the eyelids, eyelashes and brows. (Ask client to close eyes), say: eyelids close completely, no inward or outward turning of the eyelashes, eyelashes and brows are evenly distributed, no redness, swelling or lesions. Eyebrows are symetrical bilaterally.

Inspect the sclerae, conjunctiva, iris, cornea.
State “I am going to inspect the conjunctiva”. For the bulbar use thumb to hold upper lid, have client keep head straight, have client look side to side then up toward the ceiling. For the palpebral conjunctiva- 1st place thumbs bilateral at the level of the lower bony orbital rim and gently pull down to expose the palpebral conjunctiva and ask client to look up. Use pen light shine from side into eye to inspect the cornea.

State “ the conjuctiva is clear moist, smooth ,free from foreign bodies, no swelling, or redness; and sclera is white and iris is round, flat, evenly colored, cornea is transparent with no opacities .

Eye Function
Perform the confrontation test- position myself 2 feet away from the client at eye level. Have the client cover their left eye while I cover my right eye and look directly at each other, eye to eye. Extend arm straight out equal distance between each other. Come in to center from both directions and then up and down to center and down to up in center and see when each sees the finger. Normal degres to see perfiferal vision inferior 70, superior 50 temporal 90, nasal, 60. State after test “client has normal peripheral vision in all 4 fields, CN 2 intact”.

Test the extraoccular eye movements- Cardinal Fields of gaze – looking up to right, directly right, down right, and down left, and directly left, and up left. Not up and down. 3 per side. Cranial Nerves 3,4,6 Instruct client to follow finger and move through the 6 cardinal positions of gaze in a clockwise directions. State “client has smooth and symmetric eye movements through all 6 fields, CN 3, 4, 6 intact”

Corneal light reflex-hold penlight 12 inches away from the clients face, shine light toward the bridge of the nose, while the client stares straight ahead, not the light reflected on the corneas. State “look straight ahead… client has symmetrical light reflection in both eyes and parallel alignment”.

* Test pupillary response to light and accommodation (CN 3) Darken room, ask client to focus on an object, accommodation * Hold finger 12 in from client move it closer Patient moves focus of vision from distant point to a near object constrict * Client has normal pupillary response, pupils constrict

shine light by bringing it in from side - laterally and observe for pupillary reaction. State “client has pupil constriction bilaterally”

Ears
State all parts as you inspect.
External ear: inspect alignment, surface characteristics/skin. Look at the symmetry, the auricle (whole external ear), tragus (close to face – people pierce it), and lobule – ear lobe, look for lesions, discoloration, and discharge. State “ears are equal in size bilaterally, skin is smooth, no lesions, skin color is consistent with face”

Palpate the auricle and mastoid process. Start at back of ear push ear forward, then also palpate mastoid process then do front of ear, and then do tragus and cartlige. http://www2.webster.edu/~davittdc/ear/palpation/palpation.htm - example
State “there is no tenderness palpated on the auricle and mastoid process”

Nose
Inspect and palpate External nose, symmetry, lesions, skin color. To palpate the external nose start at the top bridge with thumb and index finger and gently palpate down to nostrils. During palpation ask if they feel tenderness. https://www.youtube.com/watch?v=N6fJ9xmPBGA -- example State “skin color is consistant with face, nasal structure is symmetric no lesions, and client has no tenderness upon palpation”. Then occlude each nostril to check breathing and ask client each time if they are able to breath. State “client is able to sniff through each nostril”. Mouth and Pharynx Inspect the lips, gums, buccal mucosa, hard and soft palates, floor of mouth for color and surface characteristics. Look at the lips to note smoothness, moistness and no lesions or swellings. For gums ask the client to open the mouth and with gloves retract the client’s lips and cheeks to check for color and consistency. For the buccal mucosa use a penlight and tongue depressor to retract the lips and cheeks to look for color and consistency. For the hard and soft palates ask the client to open the mouth wide while you use a penlight to look at the roof, look at the color and integrity. For the floor of the mouth have the client open the mouth and lift the tongue. Inspect for lesions and coloring. State Lips are smooth and moist, without lesions and swelling. Gums are pink, moist, firm and tight. With no lesions or masses. The buccal mucosa is pink, tissue is smooth, moist without lesions . The hard palate is pale with transvers rugae, the soft palate is pink spongy and smooth. Floor of mouth smooth, shiny, pink, no lesions”. Inspect the oropharynx: note anteroposterior pillars, uvula, tonsils, posterior pharynx, and note mouth odor. While mouth is wide open note any foul odors. To inspect the uvula have the client open the mouth wide and apply the tongue depressor (halfway b/t the tip and back of tongue) and shine penlight into the client’s mouth. Note the characteristics and positioning of the uvula, have the client say ahhhh, and watch for the uvula and soft palate to move. To inspect the tonsils and with the patient saying ahhh look at the tonsils for color, size and exudate or lesions. Grade the tonsils. Inspect the posterior pharyngeal wall, while the depressor is still in place shine the pen light on the back of the throat and note any exudate and lesions. Anteroposterior pillars: state that they are visible. State “Anteroposterior pillars are pink, no lesions or exudate. No foul odor noted, no redness or exudate of the uvula or soft palate, uvula rises symmetrically. Tonsils have no redness, swelling, or exudate and they are pink and symmetric +1. The posterior pharynx is pink without exudate or lesions.”. Inspect the teeth for color, dental carries and missing teeth. - Ask the client to open her teeth, not the number of teeth, color and condition. Note any repairs or cosmetics. State “Client has 28 teeth, all are white, no dental carries, no missing teeth, no repairs, no cosmetics”. Inspect tongue for color characteristics, symmetry, movement (CN 12 XII)- Ask client to stick out tongue, inspect for color, moisture, size, and texture.. State “Tongue is pink, moist, moderate size, with papille., symmetrical no lesions, nodules, ulcers present. Ventral surface is smooth, shiny, pink, or slightly pale, with visible veins, and no lesions. Press tongue against check on each side. Cranial Nerve 12 is intact”. Have client say “ah” test CN10: State “Clients Uvula rises on saying ah so cranial nerve 10 is intact.” Neck Inspect for symmetry and smoothness of neck and thyroid.- Observe the client’s slightly extended neck for position, symmetry, and lumps or masses. Shine a light from the side of the neck across to highlight any swelling. State “neck is symmetric with head centered and without bulging masses”. Palpate lymphnodes: preauricular, postauricular, occipital, tonsillar, submandibular, submental, superficial cervical chain, posterior cervical, deep cervical, supraclavicular bend forward with clavical.. – After palpation state “no enlargement or tenderness of lymph nodes

Palpate the carotid pulses. Do one side at a time. Use middle and index finger to palpte the artery. State “pulses are equal bilaterally +2”

Palpate the tracheal position. Place your thumbs in the sternal notch. Feel each side of the notch and palpate the tracheal rings. The first upper ring above the smooth tracheal rings is the cricoid cartilage. State “Trachea is midline”

Palpate the thyroid gland. Stand behind the client and ask the client to lower the chin to the chest and turn the neck slightly to the right. This will relax the client’s neck muscles. Then place you thumbs on the nape of the neck with you other fingers on either side of the trachea below the cricoid cartilage. Use your left fingers to push the trachea to the right. Then use your fingers to feel deeply in front of the sternomastoid muscle. Ask the client to swallow as you palpate each side. State “the thyroid is not palpable”. Inspect and palpate ROM: do with and without resistance ask client to turn head left to right, each ear to each sholder, chin to chest, and left to celing. Place hand on each side of face and have patient try and touch ear to sholder to show resistance and do under neck and behind head. State “ Smooth and controlled movements full ROM, full ROM against resistance, muscle strength grade 5.” Shoulder Shrug- Cranial Nerve 11- Ask client to shrug with and without resistance – put hands on the client’s shoulders to give resistance to assess the trapezius muscle. State “symmetric, strong contraction of the trapezius muscles, cranial nerve 11 is intact”. 2nd Section you can draw Abdomen Equipment needed for this section: cotton ball, paper clip, reflex hammer, Inspect skin, characteristics, contour, pulsations, movement, umbilicus symmetry. State “Skin is light pink and evenly pigmented no obvious lesions, redness. umbilicus is midline at lateral line. Abdomen is flat, symmetric, evenly rounded, a slight pulsation of the abdominal aorta is visible (in the epigastric region)”. Auscultate all 4 quadrats starting at RLQ-RUQ-LUQ-LLQ (RLQ clockwise), you should hear bowel sounds, take at least a min per quad State “Bowel sounds heard in all 4 quadrants” Auscultate the aorta and renal arteries (slightly below aorta) for bruits using the BELL. State “no bruits are heard.” Percuss all 4 quadrants for tone. State that “Generalized Tymphany is heard over the abdomen because of air in the stomach and intestines. Dullness over liver (at rib cage on right side) and spleen (at rib cage on left side) Palpate all quadrants, Light and deep. For light using one hand, start in RLQ going 1cm deep in a dipping motion. Circle. Gently lift fingers and move to next area. For Deep use both hands one place on the other and go 5-6 cm deep. (deep may cause a normal mild tenderness). State that “Abdomen is non tender and soft”. Palpate the liver- stand at the clients right side. Place my left hand under the clients back at the level of the 11-12th ribs. Lay right hand parallel to the right costal margin (finger tips should point to the clients head). Ask the client to inhale, then compress upward and inward with my fingers.State “liver is not palpable”. Palpate Midline for aortic pulsation. Use thumb and index or 2 hands and palpate deeply into the epigastrium, slightly to the left of the midline. Assess pulsation of the abdomonal aorta. State “A moderate strong regular pulse. Neurologic Assess touch sensation Test dull and sharp sensation and light touch of face, lower arms, hands, lower legs, feet. Use a paper clip with the pointy end and dull end and cotton piece on face, lower arms, hands, lower legs, and feet. Each time ask the patient if they can feel it and if the correctly identify what I used. Be able to identify sharp, dull touch. State “the client correctly identifies the sharp, dull, and light touch stimuli”. Assess coordination Touch nose with alternating index fingers. Have client extend arms out and touch nose with index fingers (alternating). State “client touches nose with smooth accurate movements, with little hesitation” Run heel down tibia. Ask the client to lie down and run the heel down the tibia. And repeat with other leg and foot. State “Client is able to run each heel down each shin smoothly”.

Romberg Test. Ask the client to stand erect with arms at side and feet together. Note any swaying, then have client close their eyes 20 sec. (I will be standing at the side with my arms in front needing to catch them and at the back to catch if my client starts to fall.)
State “Client stands erect with minimal swaying with eyes open and closed”.

Inspect Gait: normal, heel to toe, on toes, on heels. State “Gait is smooth and steady and arms swing at sides. Client maintains balance with tandem walking. Client walks on heels and toes with little difficulty.

Reflexes
Test Biceps, triceps, brachioradialis, patellar, and Achilles.

Biceps
Ask client to partially bend arm at the elbow, with palm up. Place your thumb over the biceps tendon and strike your thumb and strike your thumb with the thumb with the pointed side of the reflex hammer. Repeat on the other side. State “the bicep reflex is +2

Triceps
For the Triceps reflex, ask the client to hang the arm freely (limp) while I support it with my nondominant hand. With the elbow flexed, use the flat side of the reflex hammer to tap the tendon above the olecranon process. When hitting patient use the flat side. Repeat on the other arm, this
State, “Quadriceps muscle contacts, triceps reflex +2,

Brachioradiali
For the Brachioradialis Reflex, ask the client to flex the elbow with the palm down and the hand resting on the abdomen or lap. Use the flat part of the reflex hammer to tap the tendon at the radius about 2 inches above the wrist. Repeat for the other side, State “Elbow extends and triceps contracts, +2

Patellar
For the Patellar have the patient’s legs dangling off the side of examination table. Using the flat side of the reflex hammer, tap the patellar tendon, which is located just below the patella. Repeat on the other side. State “Normal response, client has the plantarflexion of the foot, +2”

Achilles
For the Achilles reflex, with the clients leg still hanging freely, dorsiflex the foot, tap the Achilles with the flat side of the reflex hammer. Repeat on the other side. State “Client has no rapid contractions.”

Plantar
For the Babinski (plantar reflex)- With the end of the hammer, stroke the lateral aspect of the sole from the heel to the ball of the foot, curving medially across the ball. State “Toes flex but is negative for Babinski Reflex”

3rd section you can draw
Skin
State all elements out loud as you inspect
Equipment you need for this section: measuring tape,
Hands and nails: Skin, capillary refill, color of nail bed. State “I am going to inspect the nails. Nails are clean and pink, (notice for longitudinal ridging), nails are at 160 degree angle between the nail bed and skin. (press on nail for capillary refill), capillary refill is less than 2 seconds.”

Color and pigmentation: Thoroughly look over skin. State “I am going to inspect the skin. The skin is light pinkish, even in skin tone, no rashes, skin is intact, (Note any healed scars, freckles, stretch marks, moles, birth marks)”.

Temperature: Use dorsal surfaces of hands (back of hands) to assess temp. Assess the face, arms, legs State “I am going to assess the temperature. The skin is warm to touch”.

Moisture: Check under skin folds to assess moisture. State “I am going to check the skins moisture, the skin is dry”.

Texture: Use the palmar surfaces of three fingers to palpate skin texture. State “I am going to assess the skins texture, the skin is smooth and even”.

Turgor: Ask the client to lie down. Using two fingers, gently pinch the skin over the clavicle.
State “I am going to assess the turgor, the skin quickly returns to its original shape”.

Lesions: Observe the skin surface for abnormalities. (If there is one note: Color, shape, size, location, distribution, configuration, and measure it).
State “skin is smooth without lesions

Upper Extremities
State all parts out loud as you inspect
Inspect and palpate hands, arms, shoulders and joints.
Inspection-observe arm size and venous pattern, measure arms in same areas on bicept muscle to insure that they are bilaterally symmetric, look for edema and redness. In the hands and arms look at the coloration, color should be the same bilaterally.

Palpate the fingers, hands and arms, and note temperature.

interphalangeal metacarpophalangeal
Start with hands
Inspect size, shape, symmetry, swelling and color. Palpate the fingers from the distal end proximally, noting tenderness, swelling, bony prominences, nodules, or crepitus of each interphalangeal joints. Assess the metacarpophalangeal joints by squeezing the hand from each side between your thumb and fingers. Palpate each metacarpal of the hand noting tenderness and swelling.
State “the hands are symmetric, nontender, and without nodules. Fingers are straight. No swelling or deformities, same color bilaterally”.

Wrist – Inspect & Palpate
Inspect wrist size, shape, symmetry, color, and swelling. Then palpate for tenderness and nodules. Palpate the atomic snuffbox – place below thumb bones feels like a hole. State “Wrists are symmetric, without redness, or swelling. They are nontender and free of nodules”.

Elbows Inspect & Palpate
Inspect the size, shape, any deformities, redness or swelling. Inspect the elbows in both flexed and extended positions. To palpate- have the elbow flexed at 70 degrees, use your thumb and middle fingers to palpate the olecranon process – upper part of arm above elbow.

Shoulders Inspect & Palpate
Inspect anteriorly and posteriorly. For symmetry, color, swelling, and masses. Palpate for tenderness, swelling, or heat. Anteriorly palpate the clavicle, acromioclavicular joint, subacrominal area and biceps. Posteriorly palpate the glenohumeral joint (total shoulder joint), coracoid area, trapezius muscle, and the scapular area. Do top of neck down back like triangle State “Sholders are symmetricly round. No redness, sewlling, deformities, or heat. Muscles are full devloped. Clavicles and scapulae are even and symmetric. The client reports no tenderness”.

Subacrominal area

ROM for the fingers, wrists, elbows and shoulders

ROM fingers
1st ask client spread apart fingers, then make a fist, then bend the fingers down at a 90 degree angle then 4 finger up together and thumb out and then bring thumb in. Repeat, then have client do it against resistance.

State “Client has full ROM along with full ROM against resistance – muscle strength grade 5”

ROM wrist.
Ask the client to bend the wrist back and forth (up and down), ask client to then hold wrist out and turn it inward and outward (left and right). Repeat, then have client do it against resistance. State “client has full ROM of wrist along with full ROM against resistance muscle strength grade 5 ”

ROM elbows
Flex the elbow and bring hand to forehead. Straighten elbow, hold arm out with hand in a karate chop position (not flat out) and turn palm down and then palm up. Repeat then have client do it with resistance. State “Client has full ROM of elbows, along with full ROM against resistance, muscle strength grade 5”

ROM Shoulders.
Explain that this will consist of extension, adduction, abduction, and motion.
1st ask the client to stand straight with both arms straight down at the sides. Next ask the client to move the arms forward the backward with elbows straight.
2nd have the client bring both hands together overhead, elbows straight, followed by moving both hands in front of the body past the midline with elbows straight.
3rd in a continuous motion, have the client bring the hands together behind the head with elbows flexed and behind the back. Then have client do it against resistance. State “Client has full ROM, with full ROM against resistance, muscle strength grade 5”

Muscle mass and tone. State ” Muscles are fully developed and symmetric in size. Relaxed muscles contract voluntarily and show mild, smooth resistance to passive movement . All muscle groups are equally strong against resistance, with no flaccidity, spasticity, or rigidity.

Assess the pulses. Radial and brachial. State “I am going to assess the radial and brachial pulses, (check both arms), Pulses are 2+ and equal bilaterally.

Back and posterior chest
Inspect for skin, musculoskeletal development, and symmetry. State Skin light pink and evenly pigmented, there is full muscles development and back is symmetric with no lesions noted.

Inspect palpate scapula and spine have client standing and have them bend over - scapulae are symmetric and nonprotruding and equal bilateral. Cervical and lumbar spines are concave; thoracic spine is convex. Spine is straight when observed from behind. Palpate scapula and spine on each side of spine and down spine. Client reports no tenderness, pain, or unusual sensations. Temperature is equal bilaterally, no palpable crepitus.

Percuss costovertebral angle: client sitting on side of bed. Have hand on back and hit fist on hand. Performing blunt percussion over the kidney. Normally no tenderness or pain is elicited or reported, dull thud observed.

Palpate the axillary nodes

Hold the clients elbow with one hand and use the three fingerpads of your other hand to palpate firmly the axillary lymph nodes. First palpate high into the axillae, moving downward against the ribs to feel for the central nodes. Continue to move down the posterior axillae to feel for the posterior nodes, use bimanual palpation to feel for the anterior axillary nodes, Finally palpate down the inner aspect of the upper arm.
State no enlargement or tenderness of lymph nodes

Lower Extremities
State all parts out loud as you inspect

Inspect for skin characteristics, varicosities, hair distribution, musculoskeletal development and symmetry. Ask the client to lie supine, then drape the groin and place a pillow under the clients head for comfort. Observe skin color while inspecting the both legs from toes to groin. Inspect for lesions, ulcers, edema and distribution of hair. Take a measuring tape and measure in the same are to insure that legs are the same bilaterally length and width. State “Skin is light pink evenly pigmented, client shaves legs, no lesions or ulcers, (note any scars), no edema, no heat. Legs are symmetric equal bilaterally”.

Palpate for temperature all the way up each leg, texture, and pretibial edema. Use the back of the hands to palpate for temperature from feet to upper leg. Feel the texture of the leg. If edema is noted during inspection, palpate the area to determine if it is pitting or nonpitting. State “Im a going to palpate for temperature, texture and pretibial edema. Temperature is warm, texture is smooth, and no pretibial edema or atrophy”.

Palpate the pulses: dorsal pedis, posterior tibial, popliteal.

For the dorsal pedis, dorsiflex the clients foot and apply light pressure lateral to and along the side of the extensor tendon of the big toe. The pulses of both feet may be assessed at the same time to aid in making comparisons. State “I am going to palpate the dorsal pedis pulses, pulses are 2+ and equal bilaterally”.
For the posterior tibial, palpate behind medial malleolus (in the grove between the ankle and the Achilles tendons). Palpate both at the same time for comparison. State “I am going to palpate the posterior tibial pulses, pulses are 2+ and equal bilaterally”.

For the Popliteal Pulse, Ask the client to raise (flex) the knee partially. Place your thumbs on the knee while positioning your fingers deep in the bend of the knee. Apply pressure to locate the pulse. Usually detected lateral to the medial tendon. State “I am going to palpate the popliteal pulses, pulses are 2+ and equal bilaterally”.

Inspect and palpate hips, knees, ankle and joints of the feet HIPS
With the client standing, inspect symmetry and shape of the hips. Palpate for stability and tenderness. palpate the iliac crest the greater trochanter, top area of groin. State “I am going to inspect and palpate the hips. Buttocks are equally sized, Iliac crests are symmetric in height, Hips are stable, with no tenderness, no heat, temperature is warm consistant with rest of body”.

KNEES
With the client supine the sitting, with knees dangling, inspect the size, symmetry, swelling, deformities and alignment. Observe for quadriceps muscle atrophy. Palpate for tenderness, warmth, consistency, and nodules. Begin palpation 10 cm above the patella, using your fingers and thumb move downward toward the knee. State “I am going to inspect and palpate the knees. Knees are symmetric, hollows are present on both sides of the patella, no swelling or deformities, non tender and muscles are firm, no heat, temperature warm consistant with rest of body. Lower leg in alignment with the upper leg”.

ANKLE & FEET
With the client in sitting, standing, and walking, inspect position, alingment, shape and skin. Palpate ankles and feet for tenderness, heat, swelling, or nodules. Palpate the toes from the distal end proximally, noting tenderness, swelling, bony prominences, nodules, or crepitus of each interphalangeal joint.
State “Toes and feet are in alingment with lower leg. Smooth rounded prominences with prominent heels and joints. Skin is smooth and free of corns. Client Reports no pain. There is no heat, swelling, or nodules”.

ROM for hips, knees, feet, and ankles.

HIPS
With the client supine
-Raise extended leg
-Flex knee to chest while other leg is extended on bed.
-Move extended leg away from midline of body as far as possible (abduction and adduction)
-Bend knee and turn leg inward and then outward (rotation)
-Ask client to lie prone (on stomach) and lift extended leg off table (lift leg up)
Then Repeat all of these with resistance.
State Full ROM for the hip, full ROM with resistance, muscle stregth grade 5”.

Muscle tone and strength - Relaxed muscles contract voluntarily and show mild, smooth resistance to passive movement. All muscle groups are equally strong against resistance, with no flaccidity, spasticity, or rigidity.

KNEES
-Bend each knee up toward buttocks or back.
-Straighten the knee
-Walk normally
Repeat and then do again with resistance
State “Client has full ROM in knee and full ROM with resistance, muscle strength grade 5.

Ankles and Feet
-Point toes up (dorsiflexion) and down (plantarflexion)
;turn soles inward (eversion) and outward (inversion)
-Rotate foot outward (abduction) and then inward (adduction) -turn toes under foot (flexion) and then upward (extension)
State” Client has full ROM in ankles and feet and full ROM with resistance, muscle strength grade 5”

Musculoskeletal
State all parts as you inspect
Observe patient moving from lying to sitting position. Note coordination, use of muscles, ease of movements. State “ I am going to inspect the client move from a lying position to a sitting position, and inspect the coordination, use of muscles and movements.
State “Patient moves from lying position to sitting position with ease and coordination. No extra use of muscles to assist in sitting up”.

ROM for spine.
-Touch chin to chest (flexion) and look up to the ceiling (hyperextension)
-Touch each ear to the shoulder of that side.
-Have Client turn head right to left. (resistance)
-Ask client to bend forward and touch toes (observe for symmertry of shoulders, scapula, and hips).
-sit behind the client and stablize the clients hips at the pelvis with your hands and ask the client to bend sideways (left and rt), bend back to you, and twist the shoulders one way then the other.
State “Client has full ROM of spine”