Comprehensive Assessment

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Transcript
A comprehensive assessment is a complete, head-to-toe physical examination, and should be done when first encountering your patient or when changes to their health status occur. Methods of comprehensive assessment include inspection, percussion, palpation, and auscultation.
To begin, perform a general overview of your patient. Observe their mobility as they enter the room, which should be smooth and coordinated. While your patient is standing, measure their height, weight, and waist circumference. Next, with your patient in a seated position, assess their general appearance, including nutritional status, any obvious signs of distress, or physical deformities. Observe their level of alertness and orientation to person, place, time, and circumstance. You will also observe the qualities of their speech, including word selection, fluidity, and vocal clarity.
As you move through your assessment, assess your patient’s hair, skin, and nails. Check for lesions, discoloration, and changes in skin and nail texture. To assess your patient’s head and face, inspect and palpate scalp, hair, and cranium, checking for any defects or lesions. Inspect their face for expression and symmetry, which represents an intact cranial nerve VII. You can also test cranial nerves V and VII by asking them to clench their teeth, squeeze their eyes tightly shut, and puff out their cheeks. Then, using the pads of your index and middle finger, palpate the temporomandibular joint as your patient opens and closes their mouth. Lastly, palpate the maxillary sinuses and the frontal sinuses by applying firm pressure over each sinus region.
Next, move on to the eyes. Inspect the external eye structures and the conjunctiva, sclerae, and iris. Assess their near vision to test the function of cranial nerve II and assess the extraocular muscles of the eyes using the six cardinal positions of gaze, which will test cranial nerves III, IV, and VI. Lastly, use a penlight to test for PERRLA, meaning the pupils are equal, round, reactive to light, and have accommodation, which also tests cranial nerve III.
Sources
- "Seidel’s guide to physical examination" Elsevier (2023)
- "Physical examination and health assessment" Elsevier (2020)
- "Physical examination and health assessment" Elsevier (2019)
- "Health assessment for nursing practice" Elsevier (2022)