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Physical Assessment Guide
Basic Screening Physical Examination for Adults
Greeting/Introduction:
❑ Introduce yourself; provide your name, purpose, and length of time you will be with your patient. Do not address your pt. by name at this point! o “Good morning, I’m Cheryl; I will be your student nurse today. I’m here until 3:00pm working with your nurse Phil. May I do a morning assessment, it will take about 10 minutes.” (not necessarily a question) ❑ Wash your hands, check patient I.D. band, and have pt. state their name and birth date ❑ Provide for privacy, comfort, and dignity! ❑ Establish working relationship built on trust and mutual respect
Environmental Check:
❑ Call light working and within pt. reach, bed locked and in low position, side rails up/down, working suction when appropriate, items needed within comfortable/safe reach such as water pitcher, glasses, dentures, hearing aids, TV controls, phone, urinal, trash receptacle available and within easy reach ❑ Check for obstacles/clutter at bedside or route to bathroom and/or sink ❑ Medical supplies and equipment, i.e. O2 tubing and set-up, I.V. lines and machinery functioning/appropriate rate, feeding/abd. tubes and lines, chest tubes, tracheostomy supplies including emergency obturator, Foley catheter, ambulation assistive devices ❑ Tubes and Lines – follow each line from patient to device, look at connections, amount of room to move, secured in place, and labels ❑ Any surgical supplies and equipment; dressing supplies, CPM, traction, abd. pillow, Incentive Spirometer (IS),!!! ❑ Updated information on whiteboard in pt. room w/ name of nurse, doctor, nurse aid, etc. ❑ Emotional/Family support, i.e. is family/a visitor present or any visual cues of personal support such as cards, flowers, pictures, etc. ❑ Begin assessment with emphasis on accuracy, flow, and patient comfort. Get a complete set of vital signs if not already done. Begin assessment on system of greatest concern.
General Appearance/Psychosocial:
❑ Acute distress or pain or any immediate needs? ❑ Does the patient acknowledge your presence? ❑ Overall affect- normal, flat, depressed, anxious? ❑ General mood- happy, cooperative, depressed (Even though this is not an appearance, this is a first impression aspect of your assessment) ❑ Any communication barriers? ❑ Inspect for development, nutrition/hydration status/ grooming o “Patient is well-developed, well-nourished, and well-groomed….” ❑ Observe gait during, before or after the exam o “Gait steady when ambulated from to at 0930” ❑ Inspect skin over entire body throughout the exam ❑ State color and presence of lesions or other anomalies o “Skin appears pink, well-hydrated, with no obvious or reported lesions.” ❑ Inspect upper & lower extremities, including nails ❑ Complete ❑ Not Complete ❑ Follow Up ❑ Complete ❑ Not Complete ❑ Follow Up ❑ Complete ❑ Not Complete ❑ Follow Up
o “Extremities warm without edema.” o “Nail beds appear pink without lines, ridges, clubbing, or cyanosis.” ❑ Palpate radial pulses, check for cap. refill to finger tips/nail beds o “Radial pulses are 2+ with brisk cap refill” ❑ Check surgical site, any wounds or skin lesions. Consider size, location, drains, dressings present and intactness, any surgical supplies required
Head/Neck:
❑ Inspect and Palpate the head and scalp ( in an acute setting, palpate PRN only) o “Head is normocephalic with no scars, masses, lesions, or tenderness. Good hair distribution and of average texture” ❑ CN 5 (Trigeminal)-Ask patient to blink eyes, open mouth, and clench teeth. Palpate the temporal and masseter muscles as they clench. ❑ CN 7 (Facial)-Look at facial asymmetry. Ask patient to wrinkle forehead, shut eyes tightly, grin, frown, shows teeth, and puff out cheeks. ❑ Note any lesions, deformities, dressings, size and shape ❑ Hair; evenly distributed, color, texture, balding patterns ❑ Mini mental exam: LOC and orientation to person, place, time, purpose ❑ Evaluate mobility/ROM of neck o CN 11 (Accessory)-From behind; examine for shoulder asymmetry, shrug shoulders, turns head against resistance ❑ Inspect Neck o “Neck supple. Trachea midline. No neck masses.” ❑ Verbally address any issues related to this body system
Eyes:
❑ Inspect eyes for alignment and symmetry o “Eyes are symmetrical with good alignment.” ❑ Describe external eye structures o “No abnormalities of the eye lids. Conjunctiva is pink. Sclera is white. No excessive tearing or discharge.” ❑ Test extra ocular movements o CN 6: Perform H pattern 15 - 18 inches from the patient nose. Finish with convergence (AKA: 6 cardinal fields of gaze) o CN 3, 4, and 6 (Oculomotor, Trochlear, Abducens) - PERRLA, direct and consensual responses, ROMs using “H” pattern, convergence, accommodation. ❑ “Extraocular movements for cranial nerves 3, 4, and 6 intact.” ❑ Check for papillary response to light, and accommodation. o “Pupils 4mm constricting to 2mm, round regular, equally reactive to light. Pupils accommodate to near and far vision.” ❑ Verbally address any issues related to this body system ❑ Complete ❑ Not Complete ❑ Follow Up ❑ Complete ❑ Not Complete ❑ Follow Up
o Scoliosis: Lateral (sideways) curvature of the spine greater than 15 degrees. ▪ “Spine with good ROM and no signs of scoliosis.” ❑ Palpate spine o “Spine straight with no flattening or displacement of the spinous processes.” ❑ Auscultate all lung fields, correctly placing the stethoscope on the chest wall, & stating which lobe is being assessed at each listening site. ❑ Auscultates throughout complete inspiratory and expiratory cycle ❑ Describe breath sounds auscultated o Tracheal Breath Sound: very loud and relatively high-pitched over the trachea. The inspiratory and expiratory sounds are equal in length. o Vesicular Breath Sound: soft and low-pitched and heard over most of the lungs. Inspiratory sounds are longer than the expiratory sounds. o Bronchial Breath Sound: very loud, high-pitched and sound close to the stethoscope. There is a gap between the inspiratory and expiratory phases of respiration, and the expiratory sounds are longer than the inspiratory sounds. If these sounds are heard anywhere other than over the manubrium, it is usually an indication that an area of consolidation exists. o Bronchovesicular Breath Sound: of intermediate intensity and pitch. The inspiratory and expiratory sounds are equal in length. They are best heard in the 1st and 2nd ICS (anterior chest) and between the scapula. When these are heard anywhere other than over the mainstem bronchi, they usually indicate an area of consolidation. ▪ “Vesicular breath sound heard over the upper middle and lower lobes. No adventitious breath sounds.” ❑ Palpate for costo-vetebral angle tenderness (CVAT) o “No CVA tenderness.” ❑ Any use of accessory muscles, overall chest expansion, all equal bilaterally? ❑ Verbally address any issues related to this body system
Anterior Chest:
Lungs:
❑ Inspect chest and describe any abnormal findings o “Anterior chest symmetrical without lesions or deformities. Good excursion” ❑ Auscultate all lung fields, correctly placing the stethoscope on the chest wall, & stating which lobe is being assessed at each listening site ❑ Auscultates throughout complete inspiratory and expiratory cycle without lifting the stethoscope prematurely prior to listening for end expiratory wheezes ❑ Describe breath sounds auscultated ▪ “Vesicular breath sound heard over the upper and middle lobes. No adventitious breath sounds.” ❑ Verbally address any issues related to this body system
Heart:
❑ Inspect for lifts and heaves ❑ Complete ❑ Not Complete ❑ Follow Up ❑ Complete ❑ Not Complete ❑ Follow Up
o “No visible lifts or heaves.” ❑ Palpate for point of maximum impulse (PMI: 5 th^ ICS at MCL), lifts & heaves o Palpate PMI and assess rate and rhythm. Place finger flat on chest over heart. Ventricular impulses should not heave or lift your fingers. o “Apical pulse discrete with regular rate and rhythm. No palpable lifts or heaves” ❑ Auscultates heart appropriately, in all listening areas (aortic, pulmonic, tricuspid, and mitral areas) & state which area is being assessed o Auscultate “APE to Man” with diaphragm and back again with the bell. With the diaphragm you can hear the snap of the high-pitched S1 and S2, arotic or mitral regurg, and pericardial friction rubs. With the bell you can hear the low-pitched sounds of the S3 and S4, mitral stenosis, and most murmurs. ▪ “S1 and S2 heard. No extra heart sound.” ❑ Observe carotid arteries for bruits, any JVD ❑ Verbally address any issues related to this body system
Abdomen:
❑ Correct positioning (knees bent, arms at side) and draping ❑ Inspect for contour, bulges, pulsations, lesions, etc. o “Flat (or round) abdomen without obvious masses, lesions, or palpations.” ❑ Auscultate all 4 quadrants for bowel sounds o “Normoactive bowel sound present in all 4 quadrants.” ❑ Percuss abdomen in all 4 quadrants o Usually tympany heard over intestines and dullness heard over liver and spleen. ❑ Palpate all 4 quadrants of abdomen using light and deep pressure for masses or organomegaly o “No tenderness or masses noted.” ❑ Palpate liver & spleen o “Edge of liver palpable at right coastal margin. Spleen and kidneys not palpable.” ❑ Palpate inguinal lymph nodes and pulses o “No inguinal lymph nodes and pulse palpable and femoral pulses strong.” ❑ Verbally address any issues related to this body system
Lower extremities:
❑ Inspect and palpate for pre-tibial edema o “No pre-tibial edema.” ❑ Palpate pedal and posterior tibial pulse o “Pedal and posterior tibial pulses strong.” ❑ Inspect feet for lesions and nail deformities / fungal infections o “No deformities or lesions of the feet. Toe nail beds pink without lesions.” ❑ Color, temperature, moisture, sensation, any varicosities ❑ Verbally address any issues related to this body system ❑ Complete ❑ Not Complete ❑ Follow Up ❑ Complete ❑ Not Complete ❑ Follow Up
UNRS 212 Physical Assessment Guide Updated 8/11 by C. Boyd
