IN PARTIAL FULLFILLMENT FOR THE REQUIREMENTS IN THE SUBJECT HEALTH ASSESSMENT

Submitted to: Mr. Jefferson Colon

Submitted by: Julian, Jana Rio M. BSN I-IV

1. Performing Hand Hygiene *Wash your hands for a minimum of 15 to 20 seconds following the correct sequence or areas to be washed first. Rinse properly and dry off using a clean towel. If possible, try not touching the faucet or any handle in the washroom. 2. Gather all equipment need *Be sure to clean the equipment before going to the client. The equipment varies depending on what area will be assessed. 3. Identify client and explain the procedure *The rationale of doing this is to make sure that you have the correct client that will be assessed and giving him/her knowledge on what you are about to do. 4. Instruct client to void before doing the exam *The rationale of doing this is to make sure that the area involved will be assessed properly and to make client more comfortable with an empty bladder. 5. Assist client to change into hospital gown and provide privacy *Wearing a hospital gown is the most convenient attire when assessing a client. Make sure that you will be giving privacy as to maintain dignity of client. GENERAL SURVEY 6. Physical Appearance Normal Appears like stated age Sexual development is appropriate to gender and age Alert, oriented, responds appropriately Skin tone is even, intact with no obvious lesions Abnormal Appears older or younger Delayed or advanced puberty Confused, drowsy, lethargic Palor, Cyanosis, Jaundice, Erythema (redness), presence of lesions Immobile, mask-like, asymmetric, drooping Respiratory signs: Shortness of breath, wheezing Pain: Grimace, Other Cases: Turner’s Syndrome

Age Gender

Level of Consciousness Skin Color

Facial Features Overall

Symmetrical with movement No signs of acute distress

holding/guarding body part, knees drawn up over the abdomen 7. Body Structure Normal Height appears within normal range, for age, genetic heritage. Abnormal Excessively short or tall Other Cases Gigantism: experienced by children Aromegaly: experienced by people 18 > Simmonds: low growth hormone Cushing’s Syndrome: Thin extremeties, with buffalo hump

Structure

Nutrition

Weight appears within normal range for height, body build, fat distribution. Body parts look equal bilaterally and are in relative proportion to each other. Clients stand comfortably erect.

Symmetry

Emaciated, Cachectic (Tissue wasting), Obese, Fat concentration in face, neck, trunk, arms, and legs Body parts are not proportioned

Unilateral Atrophy: Loss of muscle volume Hypertrophy: Increased muscle volume

Posture

Position

Body Build and Contour

Client comfortably sits on a chair or on the bed with arms relayed at the sides, head turned to the examiner. Slender, medium build, stocky or muscular.

Stiff, tense, with fidgety movement, shoulders humped, looks depressed Client is curled up in fetal position; leaning forward with arm braced on chair Thin; muscle wasting; obese *Things to remember: 1. Endomorph: fat 2. Mesomorph: normal 3. Ectomorph: thin

8. Mobility Normal Base is wide as the shoulders; foot placement is accurate Abnormal Exceptionally wide base, staggered, stumbling, limping with injury Paralysis; jerky, uncoordinated Other Cases 1. Spastic 2. Scissor 3. Propulsive 4. Steppage 5. Waddling

Gait

Range of Motion

Full mobility of each joint; movements are

deliberate and accurate 9. Behaviour Normal Client maintains eye contact, expressions are appropriate to the situation Client is cooperative; comfortable with examiner; interacts pleasantly. Client speaks clearly; stream of talking is fluent, even; word choice is appropriate Clothing is appropriate to the climate and age group; looks clean and fits the body; Appears clean and groomed; appropriate for age, occupation, and socio-economic group; hair is brushed or groomed.

movments

Facial expression

Abnormal Flat, depressed, angry, sad, anxious

Other Cases

Mood and Affect

Hostile, distrustful, suspicious, crying

Speech

Dress

Difficulty in talking; abnormal pitch or volume; voice is hoarse or whispered; slurred speech; constant talking Trousers are too large and held by belt; looks unclean; Unkept hair; Absent makeup

Personal Hygiene

INTEGUMENTARY SYSTEM 10. Inspect skin for color, pigmentation, and lesions.

Color

Normal Whitish pink, or brown color; Depends on race.

Abnormal Cyanotic (bluish); Jaundice (yellowish)

Other Cases 1. Pallor: decreased visibility of normal oxyhemoglobin 2. Carotenemia: excessive carotene 3. Hyperemia: increased blood flow 4. Erythema: redness

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of skin Xanthoma Striata: Yellowish discoloration of palmar and digital creases Addison’s disease: bronze-like skin due to deficit in cortisol Acanthosis Nigricans: brownish skin due to use of steroids and obesity Albinism: generalized whiteness; Vitiligo: absence of melanin Erythematosus: “butterfly rash” Cloasma and Linea nigra: seen in pregnant women

Temperature For Palpation: Palpate all nonmucosal skin surfaces using dorsal surfaces of hands.

Warm and equal bilaterally; hands and feet maybe cooler than rest of body.

Hyperthermia

11. Inspect hair distribution, texture, moisture all over the body. Normal Body is covered with vellus hair; terminal hair is found in eyebrows, eyelashes, scalp and in axilla and pubic hair areas. Abnormal Absence of pubic hair (unless purposely removed) Other Cases 1. Traction Alopecia: hair loss in linear formation 2. Hirsotism: excess facial and body hair 3. Trichotillomania: areas of broken-off hair in irregular patterns

Distribution

Texture Evaluate texture using

Feels smooth, even, and firm except when

Roughness on exposed areas; Hyperkeratosis

finger pads, check abdomen and medial surfaces of arms first. Moisture For Palpation: Palpate all nonmucous membrane skin surfaces using dorsal surfaces of hands and fingers.

there is significant hair and silk-like growth. Skin is dry with minimum perspiration, moisture vary from one area to another. Excessive dryness; profuse sweating 1. Xerosis 2. Diaphoresis

12. Inspect nails for characteristic, color, texture, shape and configuration. *Note for capillary refill. Color Abnormalities: 1. Leukonychia: white striations in the nail bed 2. Leukonychia totalis: nail bed is white due to hypercalcemia 3. Melanonychia: brown color of nail plate 4. Cyanotic: bluish nails 5. Splinter hemorrhage: red or brown linear streaks nail bed 6. Lindsey’s Nails: white proximal end and pink distal portion of nailbed 7. Onychomycosis: yellow or white hue 8. Terry’s Nails: whitish band Shape and Configuration Abnormalities: 1. Koilonychia: thin spoon nail with cuplike depression 2. Clubbing: Angle of nailbed is 160 degrees 3. Beau’s Line: transverse furrow in the nail plate 4. Oncholysis: separate of nail from nail bed 5. Caronychia: painful red swelling 6. Sublingual hematoma: purpura or ecchymosis under nail plate 7. Onychocryptosis: distal portion of nail plate is embedded in periungal tissue 8. Eggshell nails: curved under nail edge 9. Onychatrophia: nail atrophy or shrinking 10. Onychorrhixis: nail is split in lengthwise 11. Pterygium: abnormal cuticle that overgrows the nail Texture *Nailbase must be firm *Clubbing is due to prolonged hypoxia (chronic bronchitis, emphysema, heart disease)

13. Palpate for temperature, texture and moisture. Normal Warm and equal bilaterally; hands and feet maybe cooler than rest of body. Feels smooth, even, and firm except when there is significant hair growth. Skin is dry with minimum perspiration, moisture vary from one area to another. Abnormal Hyperthermia

Temperature Palpate all nonmucosal skin surfaces using dorsal surfaces of hands.

Roughness on exposed areas; Hyperkeratosis and silk-like 1. Xerosis 2. Diaphoresis

Moisture For Palpation: Palpate all non-mucous membrane skin surfaces using dorsal surfaces of hands and fingers.

14. Perform skin turgor/skin pinch and mobility. Procedure Palpate skin turgor at dorsal surface which reflects the skin’s state of hydration HEAD AND FACE 15. Inspect the skull for shape, size, masses, nodules, and lumps. Procedure 1. Have patient sit in a comfortably position. 2. Face the patient with client’s head in level with yours. 3. Inspect for symmetry. Normal Shape: Normocephalic Abnormalities 1. Hydrocephalus: enlargement of head without enlargement of facial structure 2. Acromegaly: abnormal enlargement of skull with bony facial structure 3. Craniosynostosis: abnormal shape of skull at right angles 4. Anencephaly: absence of brain and skull 5. Microcephaly: circumference of head is smaller than average. Abnormal Structures are deformed; Asymmetry of face Other Cases Normal Should return to its original contour rapidly. It takes about 12 seconds. Abnormal Poor skin turgor; Does not go back immediately.

Face

Normal Symmetrical; Palpebral fissure should be equal *Slight variations are common

Shape

No edema; Disproportionate structures

Slanted eyes with inner epicanthal folds; a short flat nose and a thick protruding tongue; Facial skin is shiny, contracted and hard; face is immobile and expressionless

Hypertelorism: abnormally wide distance between the eyes.

16. Inspect face for symmetry~ CN5.

17. Perform test for CN7. Facial Motor Exam Abnormalities

*Forehead and Upper lid Innervation 1. 2. 3. 4. Eyebrow elevation Forehead wrinkling Frowning Tight Closing of the eyes

1. Unless bilateral lesion, does not affect forehead 2. Mouth paralysis is overcome by emotional expression 3. Ipsilateral forehead and lower face paralysis

*Lower Face innervation 1. 2. 3. 4. 5. Showing teeth Whistling Puffing cheeks Natural smile Test or inquire about Taste Sensation

18. Inspect and palpate scalp, hair, and cranium. Normal Scalp should be pale white to pink in lightskinned people and light brown in darkskinned people. Dark to pale blonde Abnormal Infestation, dandruff Other Cases Head lice (Pediculosis Capitis)

Scalp

Hair

Patches of gray hair

that are isolated or occur in conjunction with scar

19. Palpate temporal artery – CN5 Motor 20. Palpate frontal and maxillary sinuses for tenderness. 21. Percuss frontal and maxillary sinuses for tenderness. 22. Auscultate temporal artery for bruits. EYES 23. Inspect eyebrows and eyelashes for hair distribution and alignment. Normal Symmetrical; evenly distributed; bilateral Abnormal Absence of eyelashes; infection near areas

Eyelashes Eybrows

24. Inspect lids for skin characteristics, color, and position. Normal Symmetrical; client can move both eyelids; normal lid margins are smooth with lashes evenly distributed Abnormal Drooping; infections; tumors; excessive blinking; swelling Other Cases 1. Lagophthalmos: inability to bring about complete lid closure 2. Eyophthalmos: disparity of palpebral fissure 3. Enophthalmos: disparity in size of globe 4. Entropion: inversion of lower lid 5. Ectropion: eversion of lower lid 6. Hordeolum: acute inflammation 7. Chalazion: chronic inflammation 8. Belpharitis: bilateral inflammation

Eyelids

25. Inspect bulbar and palpebral conjunctiva, note for color sclera and iris. Normal Abnormal 1. Gently pull down Increased lacrimation; reddish eyelashes and place a bulbar conjunctiva sterile cotton-tipped Pinguecula: yellow nodule on the applicator above the lid nasal side of bulbar conjunctiva margin. Pterygium: unilateral/bilateral 2. Gently exert downward triangle shaped encroachment pressure. 3. Inspect Palpebral Conjunctiva for infection and swelling 4. Return eyelid to its normal position. Sclera White sclera; small blood Jaundice; bluish sclera vessels; tiny brown patches (Osteogenesis Imperfecta)

26. Inspect and palpate the lacrimal gland, asses for color, swelling and exudates. Normal Abnormal Other Cases Lacrimal apparatus No enlargement, Mucopurulent 1. Dacroadenitis: swelling, redness, discharge; overflowing acute exudates; minimal tears (Epiphora) inflammation tearing 2. Dacrocystisis: inflammation and painful swelling beside nose and near inner canthus 27. Test for corneal reflex (Blinking and tearing) Procedure 1. Instruct the client to look straight ahead. 2. Focus a penlight on the corneas from a distance of 12 to 15 inches away from midline. 3. Observe location of reflected light on the cornea. Normal Reflected light should be seen in the center of each cornea Abnormal 1. Strabismus: deviation of one eye 2. Esotropia: inward turning of the eye 3. Exotropia: Outward evading of eye

28. Inspect pupils for size, shape and symmetry. Normal Black pupils, round, and of equal diameter, ranging from 2-6mm; brisk constriction to direct light; Abnormal 1. Miotic Pupils (<2mm constriction) 2. Mydriatic Pupils (>6mm dilation) Pupils with irregular shape

Pupils

Asses Client’s 29. Direct and consensual reaction to light and accommodation. 30. Visual fields by confrontation (CN II). 31. Six cardinal gaze (EOM). Normal Procedure: Both eyes should move smoothly 1. Place client in sitting and symmetrically in each of the position, facing you. six fields of gaze 2. Place non-dominant hand just under the client’s chin as a reminder to keep the head still. 3. Ask client to follow an object with eyes. 4. Move object through the six fileds of gaze in a smooth and steady manner. 5. Note client’s ability to move eyes in each direction. 6. Move the object forward 5 inches away from face. 7. Observe for convergence of gaze

Abnormal Lack of symmetrical mov’t; abnormal eye mov’t; 1. Opthalmoplegia: paralysis of one/more optic muscles 2. Vertical gaze: paralysis of upward gaze 3. Paralysis of horizontal gaze

32. Asses visual acuity (Snellen’s) Procedure 1. Ask client to remove corrective lenses if he/she wears them. 2. Cover one eye. 3. Ask him to read letters on one line going downward until he can no longer discern the letters. EARS

33. Inspect and palpate auricle/pinna for color, symmetry, position, and palpate for tenderness. Normal Abnormal Other Cases External Ear Same color; pain Pale, cyanotic; 1. Microtia: tenderness; edema abnormally large ears 2. Auricular hematoma: damaged/mutilat ed ear. 3. Perichondritis: edematous, painful ear. 4. Carcinoma: tumor on external ear 5. Battle’s sign: hematoma behind ear over mastoid bone 34. Inspect external auditory canal for color, patency. Note color and gloss and state characteristics of tympanic membrane. 35. Assess client’s hearing acuity (Voice whisper). Normal Client is able to repeat 2 syllable word 36. Perform Weber’s Test. Normal Client should perceive the sound equally in both ears; No lateralization of sound is known as a negative Weber’s Test. 37. Perform Rinne’s test. Normal Air conduction is heard twice as long as bone conduction when client hears through the external auditory canal is no longer heard. Abnormal Client hears the sound longer through the bone conduction. Abnormal Sound localizes on unaffected ear

Abnormal Client is unable to hear the word

NOSE

38. Inspect external nose for color, shape, size, flaring and discharges, deviations. Normal Air can move through nostrils Abnormal Air cannot move through nostrils

39. Inspect the nasal cavities for color, swelling, edema, discharges, growth with the use of nasal speculum. Normal Nasal Mucosa should be pink/dull; without swellings or polyps 40. Palpate for tenderness or mass. Normal Client should experience no discomfort during palpation; sinuses should be air filled, therefore resonant to percussion Abnormal Nasal Polyps: Smoot, round masses that are pale and shiny and are noted protruding from middle meatus Nasal Septal Perforation: nasal mucosa is inflamed. Abnormal Red mucosa; swollen width copeus; clear water discharge; edematous

41. Check for patency of both nostrils. 42. Check for CN 1 (Smell Test). MOUTH AND THROAT 43. Inspect the outer lips for color symmetry, and texture. Palpate for lesions. Normal Lips should be pink and moist with no lesions or inflammation Abnormal Lips are pale; inflamed 1. 2. 3. 4. Herpes Simplex Chancre Wart Nodule

44. Examine oral mucosa, gums, teeth, using the tongue blade and penlight. Normal Abnormal Oral Mucosa Color may vary Inflamed; lesions according to race; should be moist, smooth and free of lesions

Other Cases 1. Leukoplakia: leathery, painless, white, pointed-looking palates 2. Apthous ulcer:

Gums

Teeth

Lightly colored; gum margins should be well defined with no pockets existing between gums and teeth Presence of 32< teeth

Inflamed

small, round white ulcers. 3. Stomatitis: reddish mucosa 4. Xerostoma: excessive dryness of mucosa Gingivitis: red, tender, swollen and bleeding gingiva 1. Dental Carries: white/black patches on the surface of the tooth 2. Dead tooth: darker in color and insensitive to cold 3. Hutchinson’s Incissors: teeth with serrated edges

Absence/loss of teeth

45. Inspect the outer lips for color, moisture, size, and position. Inspect the hard and soft palates. Normal Hard and soft palates are concave and pink; hard palate has many ridges, soft palate is smooth Abnormal Infection Other Cases 1. Torus Platinus: bony ridge in the middle of hard palate 2. Palatine Perforation: hole in hard palate

Palate

46. Inspects the uvula for position, Oropharynx for color. 47. Inspect the tonsils for color, discharge, and size.

48. Perform taste test (CN7- Sensory). 49. Palpates tongue for nodules and lumps. Normal Tongue is in midline of mouth, dorsum of tongue is pink, moist, ruoght. Abnormal Tongue is enlarged, red, smooth, w/ absent papillae Other Cases 1. Glossitis: reddish tongue with absent papillae. 2. Candidiasis: thick, white, crudlike coating on tongue.

50. Note tongue movement and strength (CN 12). 51. Elicits the gag reflex (CN IX and X) NECK 52. Inspect neck muscles and assesses head movement and strength (CN11) Normal Muscles of neck are symmetrical with head in a central position. Patient is able t move the head, through a full range of motion. 53. Inspect and palpates for location of trachea. 54. Palpates thyroid gland to identify enlargement, nodule and tenderness. Procedure: 1. Stand behind patient. 2. Have the patient lower the chin slightly. 3. Place your thumb at back of patient’s neck. 4. Move finger pads over tracheal ring. 5. Instruct patient to swallow- palpate for nodules or enlargement. 55. Palpate and identify lymph nodes.

56. Observes for carotid artery pulsation and jugular vein distention. THORAX AND LUNGS 57. Inspects the size, shape and symmetry of the thorax and note for spinal deformities. Normal Elliptical in shape with lateral diameter that is larger than the AP diameter. Abnormal AP is larger than lateral diameter Other Cases 1. Barrel Chest: the AP diameter is equal to the lateral diameter 2. Funnel Chest (Pectus Excavatum): depression of the sternum 3. Pigeon Chest (Pectus Carinatum): forward displacement of the sternum 4. Scoliosis: lateral curvature and rotation of thoracic and lumbar spine 5. Kyphosis: exaggerated posterior curvature of thoracic spine

Chest

58. Palpate the posterior chest (Spinous process) for tenderness and spacing. Normal Muscle mass should be firm; no lesions; non tender; movement and pressure of chest against your hands should feel smooth. Abnormal Tender; lesions; delay in expansion may indicate fibrotic/obstructive lung disease.

Posterior Chest

59. Assess for tactile fremitus.

Normal Symmetrical vibration

Abnormal a. Decreased/Absent fremitus: soft voice, thick chest wall, COPD, pleural effusion b. Increased fremitus: fluid in lungs or infection

60. Note for diaphragmatic excursion (Posterior). *Abnormal: Dull sounds 61. Percuss the posterior thorax. Normal 3-5 cm distance between marks and even on each side. Right side maybe 1-2cm higher because of the location of the liver. Abnormal Shortened excursion (lungs are not fully expanding).

62. Performs respiratory excursion (Anterior). 63. Auscultate the chest using the systematic zigzag method (both anerior and posterior chest and identifies the location and type of the normal breath sounds). Normal Muffled sounds HEART 64. Simultaneously inspect and palpates the precordium for abnormal pulsations heaves/lifts ( using Z technique) Normal No visible pulsations, except at the PMI (Point of Maximal Impulse) or where the apical pulse is located, visible as a pulsation or thrust. Abnormal Neck distention and or visible pulsations in the precordial area except @ the PMI. Abnormal Sound is loud and more distinct

65. Auscultates the aortic, pulmonic, tricuspid and mitral areas at proper locations for heart sounds noting for S1 and S2 sounds; PMI. Normal S1- first heart sound (LUB); S2-2nd heart sound (DUB) S3-normally present under 34 years and below S4-may occur on young people with thin chest wall Abnormal Chest pain indicates inadequate myocardial tissue oxygenation; pulse deficit Other Cases 1. Dyspnea: labored/difficulty in breathing 2. Orthopnea: breathlessness that prevents client from

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lying down Fatigue: worse at night due to decreased cardiac output Cyanosis/Pallor: due t decreased CO that results to decreased tissue perfusion Dependent Edema: indicates heart failure Jugular Vein Distention: indicates heart failure

BREAST AND AXILLA 66. Inspect each breast and axilla while client’s hands are resting on her side, placed on hips, above the head. Note for contour, size, symmetry, discolorations, and dimpling. Normal Smooth; w/o lesions; dense breast tissue; nipple usually everted out in the same direction; no discharge Abnormal Increased vascularity of breast; nipple discharge; scaling around nipple Other Cases Gynecomstia: breast enlargement for males.

67. Performs breast-self examination, palpates the breast in a systematic manner and notes for masses, tenderness and texture. Normal Nodular and granular consistency; inferior aspect of breast is firm; non-tender Abnormal Lumps; unilateral granulation; mass; itching; swelling; tenderness Other Cases Peau d’ orange: thickening/edema of breast tissue/nipple with enlarged skin pores.

68. Assess for lymph nodes. (Axillary) Normal Non-tender; less than 1cm in diameter Abnormal Fixed; more than 1cm; painful; enlarged; matted together

ABDOMEN

69. Observe for the contour and inspect the symmetry of abdomen. Normal Contour: Flat, rounded/scaphoid Contours: 1. Flat 2. Rounded/Convex 3. Scaphoid/Concave 4. Protruberant Symmetry: Without bulging/masses Abnormal Protruberant abdomen (normal in pregnant women) *Ascites: accumulation of fluid in abdominal cavity.

Assymetrical

70. Check umbilicus for contour or hernia, observe skin characteristics. Normal Located at the center; inverted or protruding; clean and free of inflammation or drainage Abnormal Displaced umbilicus; For non preggo’s: indicates an abdominal mass/distended urinary bladder Hernia: for children

71. Note for pulsations, visible peristalsis, and movement. 72. Auscultate for bowel sounds in the four quadrants. Note the character and frequency. Normal 5-30/min or 10/sec (Borborygmi); no vascular sounds/friction rubs; irregular, gurgling and high pitched bowel sounds 73. Percuss the abdomen. Normal a. Tympany: stomach b. Dullness: liver and spleen Liver: approximately 5-10cm (2-4 in) Size at midsternal line: 4-9 cm (1.5-3 inc) Spleen: tympanic sound Abnormal Dullness: distended urinary bladder or ascites Abnormal Hypoactive: 1/15 sec Hyperactive: 1/sec

Dull sound

74. Palpate surface and deep areas, assess size, location, consistency of abdominal organs, screen mass or tenderness-light/deep. Normal Stomach: Soft, smooth, non-tender, pain free Liver: Non-palpable; lower border of the liver is smooth, firm and non-tender Spleen: Non palbable Abnormal Masses; tumors; or obstructions during palpation Pain; nodules occur with cirrhosis Splenomegaly

75. Perform special procedure (rebound tenderness, Murphy’s sign, Iliopsoas muscle, Obturator test) MUSKULO-SKELETAL- UPPER EXTREMITIES 76. Inspects nail beds for color, shape, texture and surrounding tissues. 77. Performs the capillary test/blanch test. Normal Abnormal Nail bed should regain usual color in 1-2 seconds. Nail bed regains own color after more than 2 seconds 78. Inspect muscles for size, notes for symmetry, palpates for muscle tone while client is active and then passive, palpate joints. Normal Symmetrical hands and arms; absence of muscle wasting; no edema; no tenderness, redness or increased heat Abnormal Assymetry or deformity of fingers in rheumatoid arthritis

79. Test for muscle strength bilaterally. Normal Fingers: Equal strength on both hands Wrist joint: No enlargement or discomfort or pain; symmetrical muscle strength Abnormal Enlargement along joints or discomfort/pain; Unequal strength which may indicate weakness on either side *Stereognosis: able to identify an object

80. Check for ROM asking client to move selected body parts and names exercises done. Normal Full, without difficulty Abnormal Presence of pain

81. Elicits reflexes (Biceps, Triceps, Brachioradialis)

Normal Biceps Reflex 2+ Contraction of biceps muscles with flexion of the elbow 2+ Contraction of triceps muscle with extension of forearm 2+ Flexion and supination of forearm

Triceps Reflex

Brachio-radialis or supinator Reflex

82. Conducts fine motor test. 83. Conducts light touch sensation and notes for pain and temperature sensation. Normal Light Touch Sensation: Client is able to feel the touch as light or soft on either side Pain Sensation: Client is able to tell the sensation as sharp or dull Conducts tactile discrimination 84. One and two point Normal Acceptable standard of distance that a client can no longer feel the distance bet/ two points or object is 5 millimeters 85. Stereognosis Normal Client is able to identify the given object correctly. 86. Extinction phenomenon Normal Client is able to feel both touches and is able to directly point the correct location of touch 87. Graphestesia Abnormal Feels only one stimulus suggests lesions of the sensory cortex Abnormal Increased distance between the 2 points felt suggests lesions in sensory cortex Abnormal Decreased/absent sensation Client has difficulty feeling sensation

Normal Able to identify number

Abnormal Inability to identify the number written which may indicate a lesion on the sensory cortex

LOWER EXTREMITIES 88. Inspect legs together, note skin color, distribution, venous pattern, size, lesions. 89. Measure calf circumference along legs down to the feet. Normal Symmetrical and equal circumference, size, and length. 90. Palpate skin temperature along legs down to the feet. Normal No inflammations or enlargement or pain 91. Assess for Romberg, tandem walking, heel to shin. Normal Able to do this in a straight line without losing balance 92. Assess for Homan’s sign. 93. Check for pretibial edema. 94. Check for reflexes. Reflex Quadriceps reflex/Patellar reflex Achilles reflex Plantar/Babniski reflexes Normal Quadriceps contract, lower leg extends Plantar flexion Plantar flexion without toe fanning or great toe dorsiflexion

95. Check for muscle strength. Toes Both legs Normal Good muscle strength No limitation of movement