PHYSICAL EXAMINATION

(Lower Body Assessment)

(Peripheral, Neurovascular, and Neurologic Assessment)

I. Definition

Physical Examination - a systematic assessment generally conducted to

obtain baseline data that will help the nurse
establish nursing diagnoses and plan the client’s
care, and to evaluate the physiologic outcomes
of health care and thus the progress of a client’s
health problem.

II. Equipment

-Stethoscope -Penlight -Alcohol

-Paper Clips -Percussion Hammer
-Cotton Balls -Clean Gloves
-Coin & Key -Wristwatch

Procedure Rationale
Establishing Rapport
1. Read the Physician’s Order
2. Prepare all needed materials at the
nurse’s station.
3. Perform Medical Handwashing
4. Proceed to client’s room.
5. Ask permission from client to place all
materials on the bedside table.
6. Introduce oneself. Confirm identity of
the client.
7. Explain the purpose of the procedure to
be performed.

General Inspection
1. Inspect the client’s overall appearance.
Cite ongoing treatments or adjunct
therapies. Check for presence of scars,
dressings, cyanosis, and limb pallor.

Peripheral Assessment (Upper Limb)

1. Inspect the hands. Check for color
(cyanosis/pallor/erythema).
2. Assess & compare the temperature of
the upper limbs.
3. Assess for capillary refill time (CRT).
4. Palpate the radial pulse. Assess rate and
rhythm. Compare both sides. (10s each
side).
5. Palpate the brachial pulse. Assess rate
and rhythm. Compare both sides. (10s
each side).
6. Auscultate each carotid pulse and listen
for a bruit. (10s each side).
7. Palpate the carotid pulse. Assess rate
and rhythm. Compare both sides. (10s
each side).

Peripheral Assessment (Lower Limb)

1. Inspect between toes and on the
posterior aspect of the legs for hidden
ulcers.
2. Perform a gross motor assessment of
the lower limbs. Instruct client to move
lower limbs.
3. Assess & compare the temperature of
the legs.
4. Assess capillary refill time (CRT).

Peripheral Lower Limb Sensation

1. Don clean gloves.
2. Instruct client to close eyes. Using a wet
cotton, assess light touch sensation,
starting distally.
3. Perform Buerger’s Test. Raise client’s
both feet to 45 degrees for 1 minute.
Observe for pallor of lower limbs.
Neurologic Assessment
1. Assess client’s gait. Instruct client to
walk few steps towards you (full steps).
Upon return to bed, instruct client to
perform tandem gait (heel-to-toe step).
Observe for stance and stability.
2. Romberg’s Test. Instruct client to
stand with feet together and hands on the
sides with eyes closed. Perform for 15-20s.
Ensure safety of client.
3. Assess for Nystagmus. Using a
penlight, ask the client to follow the
direction of stimulus.
4. Finger-to-Nose Test. Assess
coordination. Perform to both hands. Past-
pointing is noted in cerebellar disease.
5. Rebound Phenomenon. Ask client to
raise both arms with eyes closed. Apply a
downward force towards the client’s arms.
6. Assess for Dysdiadochokinesia.
Instruct client to perform rapid supination-
pronation of hands. Perform to both sides.
7. Tactile Discrimination. With eyes
closed and using a paper clip (both sides),
assess client’s ability to identify stimulus
(sharp or dull). Perform to random areas
of the body.
8. Stereognosis. Instruct the client to
close their eyes with their palms open
upward. Place a coin and key
(individually). Assess client’s ability to
identify object.
9. Patellar Knee Reflex. Strike the
patellar tendon with a reflex hammer (just
below the patella). Assess reflex.
10. Heel-to-Shin Test. Ask client to
assume upright position. Instruct client to
lift leg and let the heel of one leg to touch
the shin of the other leg going downwards.
Repeat 2-3x for both legs.

Summary and Documentation

1. Assist client to assume a comfortable
position.
2. Inform client of the results.
3. Remove used clean gloves.
4. Provide health education.
5. Thank and acknowledge the client.
6. Do aftercare.
7. Summarize and finalize documentation
at the nurse’s station.