Comprehensive Assessment

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.

To assess the ears, start by inspecting the external ears for position and alignment. Then, gently tug the auricle up and back for adults or down and back for children, and push the tragus to check for tenderness. Using an otoscope, inspect the canal, and the tympanic membrane for color, position, bulging, and integrity. Finally, you will test hearing using the whisper test, which will check the function of cranial nerve VIII.

Moving on to the nose, mouth, and throat, inspect the external nose for symmetry and lesions. Then, check patency of each nostril by occluding one side of the nose and asking the patient to sniff. During this time, you can also test the function of cranial nerve I by asking the patient to close their eyes and identify a common odor, like peppermint. Next, using the otoscope, inspect the external and then the internal nares including the nasal mucosa, nasal septum, and inferior nasal turbinates.

Next, ask your patient to open their mouth and use your penlight to illuminate the mouth so you can inspect the buccal mucosa, teeth, gums, tongue, salivary ducts, palate, and uvula. To test the function of cranial nerves IX and X, use a tongue depressor to look for the mobility of the uvula, which should rise as they say "ahhhhhhhhh." Lastly, ask them to stick out their tongue and move it from side to side, testing cranial nerve XII.

Move down to the neck, and assess symmetry, lumps, and pulsations. Palpate the cervical lymph nodes, and the carotid pulses one side at a time for rate, rhythm, and strength. Then, auscultate to check for carotid bruits using the bell of the stethoscope. Palpate the trachea to assess its position, which should be midline. Palpate the thyroid gland, noting the size and the presence of any nodules. Lastly, test the range of motion, or ROM of their neck; and then test cranial nerve XI by asking them to shrug their shoulders and turn their head against resistance.

Okay, moving on to the upper extremities. Start by testing ROM and muscle strength of their hands, wrists, arms, and shoulders. Palpate the radial and brachial pulses bilaterally noting rate, rhythm, and strength. Check capillary refill on at least one finger of each hand, looking for the swift return of nail bed coloration.

Alright, next is the assessment of the chest. Start by inspecting the precordium for any pulsations. Look for any obvious deformities of the chest wall like pectus excavatum, known as funnel chest, or pectus carinatum, also referred to as pigeon chest. Observe your patient's breathing pattern, while assessing excursion, depth, and rhythm. Auscultate breath sounds noting any adventitious sounds like crackles, wheezes, or rhonchi. Palpate the chest for tactile fremitus, lumps, and tenderness on both the anterior and posterior aspects.

Also inspect and palpate the scapulae and spine and percuss the costovertebral angle. Next, use the diaphragm of your stethoscope to auscultate the heart moving in an APE-To-Man pattern, meaning the Aortic valve, Pulmonic valve, Erb's Point, Tricuspid valve, and Mitral valve. While auscultating the heart sounds, listen for any murmurs, clicks, or rubs.

Moving on to the abdomen, you will inspect, auscultate, then percuss, and palpate. Begin by inspecting for contour, symmetry, and pulsations. Use the diaphragm of your stethoscope to auscultate in each of the four quadrants, noting the presence and frequency of bowel sounds. Then use the bell of your stethoscope to auscultate for vascular sounds over the aorta, and renal, iliac, and femoral arteries. Percuss all quadrants, noting if the tone matches the underlying structures. Next, use light and then deep palpation in all quadrants.

Finally, assess the lower extremities. Assess symmetry, ROM, and strength of the toes, feet, ankles, and knees. Palpate the popliteal, posterior tibial, and dorsalis pedis arteries bilaterally.

Alright, as a quick recap…. A comprehensive assessment is a complete head-to-toe physical examination of your patient and should be done when first encountering your patient or if they have changes to their health status. The methods of comprehensive assessment include inspection, percussion, palpation, and auscultation.