THE COMPLETE HEALTH

ASSESMENT : PUTTING IT ALL

TOGETHER

Kelompok 4 :
Cindi tri wulandari
Dava Milenia Fresha
Pipit hutria
Visca herlencia
Jodi prizaer

Stikes Syedza Saintika Padang

 A Complete examination is performed at a patient’s
first entry in an outpatient setting or initial
admission to the hospital.
 general appearance

1. Appears stated age

2. Level of consciousness
3. Skin color
4. Nutritional Status
5. Posture and Position comfortable erect
6. Obvious physical deformities
7. Mobility
gait
Use ofassistive devices
Range of motion (ROM) of joints
No invloluntary movement
Able to rise from a seated position easilly
8. Facial expression
9. Mood and effect
10. Speech : articulation, pattern, content appropraite, native language
11. Hearing
 Measurement

1. Weight
Height
2. Waist circumference
3. Compute body mass index
4. Vision using Snellen eye chart

Skin

1. Examine both hands, and inspect the nails

2. For the rest of the examination, examine the skin with the
corresponding regional examination
 Vital Signs
1. Radial Pulse
2. Respirations
3. Blood Pressure
4. BP in lowerleg : compute ankle/branchial index
5. Temperature

Head and Face

6. Inspect and Palpate scalp, hair and cranium

7. Inspect face : expression , symmetry (vranial nerve VII)
8. Palpate temporal artery, then the temporomandibular joint as the person opens and
closes the mouth
9. Palpate the maxillary sinuses and the frontal sinuses
 Eyes

1. Test visual fields by confrontation (cranial nerve II)

2. Test extraocular muscles : corneal light reflex, six cardinal positions of gaze
(cranial nerves III,IV, VI)
3. Inspect external eye structures
4. Inpect conjuctivac, sclerae , corneas, irides
5. Test pupil : size, response to light and accommodation

Darken room
6. using an ophthalmoscope, inspect ocular fundus : red reflex , disc vessels , and
retinal background.
 ears

1. Inspect the external ear : position and aligment , skin condition , and auditory meatus
2. Move auricle and push tragus for tenderness
3. With an otoscope , inspect the canal , then the tympanic membrane for color, position ,
landmarks , and integrity
4. Test hearing , whispered voiced test

Mouth and Throath

5. With ba penlight, inspect the mouth : buccal mucosa , teeth and gums , tongue , floor of
mouth , palate, and uvula
6. Grade tonsils , is present
7. Note mobility of uvula as the person phonates “ahh” and test gag reflex (cranial nerves
IX, X)
8. Ask the person to stick out the tongue (cranial nerve XII)
9. With a gloved hand, bimanually, palpate the mouth , if indicated.
neck

1. Inspect the neck : symmetry , lumps and pulsations

2. Palpate the cervical lymph nodes
3. Inspect and palpate the carotid pulse, one side at a time .
4. If indicated , listen for carrotid bruits.
5. Palpate the trachea in midline
6. Test ROM and muscle strength againts your resistance :
head forward and back , head to each side, and shoulder
shrugh (cranial nerve XI )
 Chest, Posterior and lateral
1. Inspect the posterior chest: configuration of the thoracic cage, skin characteristics,
and symmetry of shoulders and muscles.

2. Palapate; symmetric expansion; tactile fremitus; lumps or tenderness.

3. Palpate length of spinous processes.

4. Percuss over all lung fields; percuss diaphragmatic excursion.

5. Percuss costovertebral angle, noting tenderness.

6. Auscultate breath sounds, comparing side to side in upper and lower lung fields; note
any adventitious sounds.
Chest, Anterior
1. Inspect; respirations and skin characteristics.
2. Palpate; tactile fremitus, lumps, or tenderness.
3. Percuss anterior lung fields.
4. Auscultate breath sounds, comparing side to side in upper and lateral lung fields.

Heart
5. Ask the person to lean forward and exhale briefly, auscultate cardiac base for any
murmurs.

Upper Extremities

6. Test ROM and muscle strength of hands, arms, and shoulders.

7. Palpate the epitrochlear nodes.
Female Breast

1. Inspect for symmetry, mobility, and dimpling as the woman lifts arms over the head,
pushes the hands on the hips, and leans forward.
2. Inspect supraclavicular and infracalvicular areas. Help the woman to lie supine with head
at flat to 30-degree angle. Stand at the person’s right side. Drape the gown up across
shoulders, and place an extra sheet across lower abdomen.
3. Palpate each breast, lifting the same-side arm up over head, include the tail of spence and
areola.
4. Palpate each nipple for discharge.
5. Support the person’s arm, and palpate axilla and regional lymph nodes.
6. Teach breast self examination.

Male Breast
7. Inspect and palpate while palpating the anterior chest wall.
8. Supporting each arm, palpate the axilla and regional nodes.
Neck Vessels
1. Inspect each side of neck for a jugular venous pulse, turning the person’s head
slightly to the other side.
2. Estimate jugular venous pressure, if indicated.

Heart
3. Inspect the precordium for any pulsations or heave (lift).
4. Palpate the apical impulse and note the location.
5. Palpate the precordium for any abnormal thrill.
6. Auscultate apical rate and rhytm.
7. Auscultate with the diaphragm of the stethoscope to study heart sounds, inching
from tehe apex up to the base, or vice versa.
8. Auscultate the heart sounds with the bell of the stethoscope, again inching
through all locations.
9. Turn the person over to left side while again auscultating apex with the bell.
Abdomen
1. Inspect; contour, symmetry, skin characteristics, umbilicius, and
pulsations.
2. Auscultate bowel sounds.
3. Auscultate for vascular sounds over the aorta and renal arteries.
4. Percuss all quadrants.
5. Percuss height of the liver span in right midclavicular line.
6. Percus the location of the spleen.
7. Palpate; light palpation in all quadrants, then deep palpation in all
quadrants.
8. Palpate for liver, spleen, and kidneys.
9. Palpate aortic pulsation, if indicated.
Lower Extremities
1. Inspecy; symmetry, skin characteristics, and hair distribution.
2. Palpate pulses; popliteal, posterior tibial, dorsalis pedis.
3. Palpate for temperature and pretibial edema.
4. Separate toes and inspect.
5. Test ROM and muscle strenght of hips, knees, ankles, and feet.

Musculoskeletal
6. Note muscle strenght as person sits up.
Neurologic
1. Test sensation in selected areas on face, arms, hands, legs, and feet:
superficial pain, light touch, and vibration.
2. Test position sense of finger, one hand.
3. Test streognosis, using a familiar object.
4. Test cerebellar function of the upper extremities uing finger-to-nose test or
rapid-alternating-movement test.
5. Elicit deep tendon reflexes; biceps, triceps, bradicardialis.
6. Test the cerebellar function of the lower extremiries by asking the person
torun each heel down the opposite shin
7. Elicit deep tendon reflexes : pattelar and achilles
8. Test the babinski reflex
 Lower exremities
inspect legs for vericose veins

 Musculoskeletal
1. Ask the person to the walk across the room in his or her reguler
walk, turn and than walk bacl : toward you in heel-to-toe fashion
2. Ask the person to walk on on the toes for a few steps, then to walk
on the heels for a few steps
3. Stand close and check romberg’s sign
4. Ask the person to hold the edge of the bed and to perform a
shallow kneebend, one for each leg
5. Stand behind and check the spine as the person tauches the toes
6. Stabilizer the pelvis and test the room of the spine as the person
hyperextends rotates and laterally bends
 Male genitalia
1. Inspect the penis and scrotum
2. Palpate the scrotal contens, if a mass exists,
transilluminate
3. Check for inguinal hernia
4. Teach testicular self-examination
 Male rectum
1. Inspect the perianal area
2. With a gloved lubricated finger, palpate the rectal
walls and prostate gland
3. Save aa stool specimen for an occult blood test
 Famale genitalia
1. Inspect the perineal and perineal area
2. With a vaginal speculum, inspect the cervix and vaginal walls
3. Procure specimens
4. Perform a bimanual examination : servix, uterus and adnexa
5. Continue the bimanual examination checking the rectum and
rectovaginal walls
6. Save a stool specimen for and occult blood test
7. Provide tissues for the famale to wipe the perineal area and
help her up to a sitting position