ASSESSMENT BY BODY
SYSTEM
An alternate
method of
assessment
I. INTRODUCTION TO THE CLIENT
a.
b.
Establish rapport by using eye contact
- Sitting at the level of the client if possible
- Even if you feel rushed; do not convey that to the
client
Communication is extremely important
II. VITAL SIGNS
a.
b.
c.
d.
e.
f.
g.
Temperature
Pulse
Respirations
Blood Pressure
Pain Assessment
Weight/Height
O₂ Saturation
III. NEUROLOGICAL ASSESSMENT
a.
Level of Consciousness
1. Stimulus Response
b. Pupils (PERRLA)-examination of clients eyes
1. Pupils Equal Round Reactive to Light and
Accommodation
2. Means the ability of the eyes to focus on objects that are
close up and faraway
Glasgow Coma
Scale
Response
Score
Eye Opening
Spontaneous
To verbal command
To pain
No response
4
3
2
1
Motor Response
To verbal command
To painful stimuli- Localizes pain
- Flexes and withdraws
- Assumes Flexor posturing
- Assumes Extensor posturing
No response
6
Oriented and Converses
Disoriented and Converses
Uses Inappropriate Words
Makes Incomprehensible
Sounds
No response
5
4
3
2
1
Verbal Response
(arouse patient with
painful stimuli if
necessary)
5
4
3
2
1
IV. CARDIAC ASSESSMENT
a.
b.
c.
d.
e.
f.
g.
Pulses- Apical, Radial, Pedal Quality & Rate Bilaterally
Capillary Refill
Neck Veins
Edema-check feet, hands, scrotum
Heart Sounds-lub/dub, rhythm, murmurs
Sighs and Symptoms of Shock
1.Increased heart rate
2.Decreased blood pressure
Cool, clammy skin
B. CAPILLARY REFILL
Can be done on the fingers or toes
Press down on the nail bed
Color will blanch
Assess the time for the color
to return
 Capillary refill should return in
3 seconds or less
 Delay in capillary refill may
indicate impaired circulation




C. NECK VEINS
 Neck veins should be checked by having patient sit at a 45
degree angle
 In this position, the jugular veins should be flat
 Distended neck veins at 45 degrees are an indicator of over
hydration or fluid overload
NECK VEINS
Distended Veins
Flattened Veins
V. MOTOR FUNCTIONING
a.
Facial Symmetry
1. Check teeth, raise eyebrows
b. Hand grips
c. Movements & Strength of Extremities
1. Patients extends arms, check reflexes
VI. RESPIRATORY ASSESSMENT
a.
b.
c.
d.
e.
Inspection of skin color, barrel chest of emphysema
Auscultation
1.Lung sounds-wales/crackles, wheezes
Sputum-color consistency
Cough-productive, non productive
Oxygen administration and response
VII. GASTROINTESTINAL & ABDOMINAL
ASSESSMENT
a.
b.
c.
d.
e.
f.
g.
Inspection- flat, round, distended
Auscultation
1. Bowel sounds; 4 quadrants
- hypoactive, active, hyperactive, absent
2. Listen for abdominal aorta bruit
Palpation- pain?, deep to determine liver margins
Percussion- air, fluid?
Nausea, Vomiting, Dyspepsia, Anorexia
Nutrition-intake, pain when eating, appetite
Lab Values-protein, prealbumin(blood test)
VIII. FLUIDS & ELECTROLY TES
a.
b.
c.
d.
e.
Intake and Output
Peripheral Edema
Diaphoresis (excessive sweating)
I.V. Site
Lab Values- electrolytes
IX. EXAMINATION
a. Urinary Assessment a. Color, odor, amount
b. Last bowel movement
b. Stool
color, character and
consistency
c. Diaphoresis
c. Excessive sweating
d. Drainage form
dressing, drains
e. Lab Values
e. Blood, Urea, Nitrogen
(BUN), Creatinine, blood
in Stool?
X. MUSCULOSKELETAL ASSESSMENT
a.
Muscle Strength
1. Mobile? Immobile
XI. ENDOCRINE/REGULATION
a. Senses
b. Diabetic
c. Thyroid
a. Hearing, vision
b. Glucose levels, altered
levels of consciousness,
Feet/skin
c. Monitor heart rate & blood
pressure
XII. INTEGUMENTARY SYSTEM
a. Decubiti (when in
lying down
position)
b. Nutrition
a. redness, lesions,
skin to muscle & to
bone
b. Intake,
likes/dislikes,
output
XIII. PSYCHOSOCIAL ASPECTS
a.
b.
c.
Af fect of illness on role; such as work, family
Inappropriate independence, dependence?
Check for depression, suicidal ideation of needed