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211 Physical Assessment Steps
Health Assessment (NSG 121)
Herzing University
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nPhysical Assessment-- see instructor final PE checkoff on Blackboard for grading criteria
Task Steps Documentation (Verbalize Findings)
Intro ● Wash hands ● “Hello, my name is _____. I will be performing you assessment today.” ● ID pt - “Can you tell me your name and birthday?” ● Person, place, time - “Can you tell me where you are, what a day it is, and who the current president is?” ● Recent and remote memory ● “Are you in any pain today? If you are, can you rate it on a scale from 0 to 10?” ● “Do you have any allergies that we should be aware of?” ● Everything we discuss and do will be kept private and will only be discussed with care team” ● “Do you have any questions or concerns? Please know you can refuse anything at any time” ● provide privacy (ex: curtain drawn)
● “Pt’s name is _____ and was born _____.” ● “Pt is AO x 4.” ● “Pt confirms/ denies pain.” ● “Pt reports nka/ _____.” ● “Pt expresses understanding of confidentiality and right to refuse care.”
Skull ● Configuration, scalp, hair quality: 一 Inspect scalp for bumps, swelling, bruising, lesions ○ Inspect hair for color, distribution, healthiness ○ “Is it okay if I touch your head?” - touch head and hair for bumps, swelling, bruising, lesions, or pests ● CN VII: facial movements - frown, smile, brows, puff cheeks 一 “Can you frown, smile, move brows up and down, puff your cheeks for me?” ● CN V: facial sensation - cotton ball touch 一 “Can I touch your face with this cotton ball and you
● “Pt’s head presents normal cephalic.” ● “No/ present bumps, swelling, bruising, or lesions or pests present on skull.” ● “Hair is ____ color with equal/ unequal distribution and appears healthy/ unhealthy.”
tell me where you feel it? Can you close your eyes as well?” - touch to chin, cheeks, nose, forehead ● Palpate TMJ
● “CN VII is intact/ not intact .”
● “CN V is intact/ not intact.” ● “Pain or tenderness is/ is not noted in jaw.” ● “Sinus pain is/ is not noted.”
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○ “Is it okay if I touch your jaw? places fingers on hinge of jaw Can you move your jaw up and down and from side to side?” ○ Testing for crepitus (bone grinding) Sinuses: frontal and maxillary/facial ○ “Can I touch your face near your eyes?” ○ Press above eyes and under eyes, then tap above above eyes and under eyes for pain Spinal accessory CN XI: shoulder shrug ○ “Can you shrug your shoulders? Can you move your head from side to side? Now can you shrug your shoulders with me pushing down on them? Can you move your head from side to side with me pushing against you?” ○ Push against shoulders and head for resistance
● “CN XI is intact/ not intact.”
○ Look for red/orange ring ● PERRLA 一 Pupils, equal, round, reactive to light, accomodate (look at something far and look at something close) ○ Document resting and constricting pupil size ○ “Just look in front of you while I move this object” move finger/object close to eyes and away from eyes ● Eye movement CN III, IV, VI 一 “Follow the object with your eyes” ○ move object to right upper corner, right middle, right bottom corner, then left upper corner, left middle, and bottom left corner ○ Note nystagmus ○ Checking extra ocular muscular strength
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moist/ dry, and smooth/ rough.” “Sclera is white/ red/ pink.” “Lacrimal ducts produce enough/ not enough/ too many tears.” “Inner eyelid is healthy pink/ irritated red/ yellow color.” “Red reflex is/ is not intact.”
“Pupils are/ are not PERRLA.” “CN III, IV, and VI are/ are not intact.” “Extra ocular muscles strength is/ is not noted.”
Ears ● Inspect externals ears for bumps, bruises, lesions, swelling, check behind ears
● “No/ present bumps, bruises, lesions, or swelling noted on or
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○ “Can I look behind your ears?” ○ “Can I touch your ears? Any pain or tenderness?” palpate ears from lobe to the top, pull lobe Ear canal and tympanic membrane ○ “Can I look inside your ears?” ○ Pull the ear up and over for adults and down for kids ○ Membrane should look gray/white not red/black
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behind ears.” “No/ reports pain or tenderness upon palpation of ear.” “Tympanic tympanic membrane is intact/ perforated with greyish white/ red/ black color.”
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○ Look for cone of light - 5 oclock right and 7 oclock left ○ Note sebum Weber test ○ “Can I place this tuning fork on your forehead? Tell me if you feel the vibrations equally on both sides ○ place tuning fork top center of forehead after hitting it wrist to start vibrating Rinne AC>BC ○ Testing air conduction being greater than bone conduction ○ “I am going to put the tuning fork behind your ear, tell me when you stop hearing it and i will move it to your ear and tell me if you hear it again” ○ *hit fork to start vibration and place on mastoid process, when they say they stop hearing it, place fork in front of ear Whisper test ○ Prepare 3 2-syllabal words ○ “Can you press down on the other ear and listen with the other? Repeat back the words you hear” Auditory acuity CN VIII ○ “Tell me if you hear something” ○ *rub fingers together by ears
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“Cone is light is/ is not present at 5 o’clock on the right and 7 o’clock on the left.” Sebum..... “No/ reports lateralization of vibration with Weber test.” “Air conduction is greater than/ less than bone conduction.”
“Passed/ failed Whisper test.” “CN VIII is/ is not intact.” Auditory acuity is present/ not present
Nose ● ●
Inspect nose for bumps, bruising, swelling, lesions “Can you plug one nostril and breathe through the other?
● “No/ present bumps, bruising, swelling, or lesions noted on
Inspect skin ● Insect skin for bumps, bruises, lesions, symmetry, involuntary movement, moles, rashes, swelling, veins, tattoos
● Upper extremities is symmetrical ● no/present bumps, bruises, lesions, rashes, swelling
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Assess temperature: touch with back of hand down the arms, assess texture and moisture Test capillary refill: squeeze finger nail, should be back in 2 seconds
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Skin color is even tone or blotchy is/is not tattoo and describe Temperature is even warm to touch
Palpating pulses ● ● ●
Check radial pulse bilaterally at same time Check brachial pulse bilaterally
● ● Don’tEqual count,bilaterally, compare bounding, and describeand not able to obliterate (press hard to get rid of pulse) and rate ROM and strength: fingers ● ● ●
“Can you squeeze my fingers” “Bring thumb to pinky” “Spread your fingers apart and I will try to bring them in” both sides
● Checking for same strength on both sides. “Equal strength”
ROM: wrist ●
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“Flex and extend wrist, and do it again while i feel for crepitation ” “Turn wrist in and out”
● Free range of motion with no pain or tenderness or crepitation
ROM and strength: elbow ● Do supination and pronation ● Do flexion and extension (do it again with resistance ROM and strength: shoulder ●
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Abduction and adduction (like flapping wings) and do again with feeling shoulders, “any pain” External and internal rotation, put hands behind head and then behind back,feel shoulders, “any pain or tenderness” Do circumduction, circles with shoulders Put elbows up with hands in and touching and push down
● Note pain, tenderness, and crepitation
Motor and cerebellar systems ● “Touch each finger with thumbs and keep going faster. Next place your hands down on your thighs, and alternate flipping your hands (one facing up and one down and switch), also close eyes and touch nose each side” sensory ● ● Test sharp, dull, soft“This is what sharp, dull, and soft feels like, I am going to touch parts of your body and tell me what you feel, close your eyes”
● Patient was able to differentiate soft, dull, and sharp on different parts of body
Reflexes (do both sides) ● ●
Bicep: Ask to flex elbow, and hit own thumb with pointy part (do both sides) Tricep: hold their arm up and bent down, have them flex and extend, have them relax, hit right above back of elbow
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Look for hand or finger movement: rate: 0- Look for extension of arm: 0-4 rating, note if they are not relaxed
LOWER
Inspect Look for skin tears, symmetry, temperature, lesions, involuntary movements, EDEMA, varicose veins
Sensory Dull, sharp, and soft on different areas of the legs and feet while patients eyes are closed
Patient could correctly differentiate
- ROM (Bilaterally) a. Hips b. Knees c. Ankles
a.
b.
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d.
Hip- abduction and adduction of hips while lying down. bringing knees up to chest and back. Flexion and extend by Keeping legs straight and lifting leg up and down and then again with resistance on both sides. Rotation by putting foot on table and bring knee in and out. Knees- flexion and extension by placing foot on table and flex and extend in the air. Repeat with resistance. Ankles- Dorsiflex and plantarflex. Again against resistance. Feeling the joint. Inversion and eversion of feet. Toes- curl toes
Asking for pain or tenderness and feeling for crepitation Free range of motion for all lower extremities
- Palpating pulses a. Femoral b. Popliteal c. Post tibial d. Dorsalis pedis
a. b. c.
d.
Just verbalize femoral Find popliteal behind the knee Palpate right behind the ankle bone on inside (start lightly) Start gently right in triangles on foot.
Name and give score to all of the pulses
- Walking Watch the gait. Have patient walk towards you on heels and then on toes. Have patient walk heel to toe (line walk)
Equal steps and erect posture. No difficulty
- Standing Romberg test by having feet together and arms at the side and then close eyes and watch balance. Have patient do lunges and then swing legs forward and back. Assess for scoliosis -hip alignment and shoulder alignment -have patient slowly reach for toes and look for evenness and feeling for pain or curvature.
No swaying or slight swaying observed. No pain or tenderness with this No pain or tenderness, hip and shoulders evenly aligned Spine is equally aligned
- ROM spine Have patient lateral bend and just turn shoulders while nurse holds and stabilizes hips.
Pt able to move without difficulty
Pulmonary
Task Steps Documentation/Verbalize Findings
intro -
Inspect anterior and posterior thorax - Observe if they are in respiratory distress (labored, struggling, hyperventilating) know the signs!!!!!!!
- Observe for barrel chest (side would just as wide as across
● Patient has unlabored breathing and no signs of respiratory distress, flared nostrils, synosis, sweating (diaphoresis), tripod position, rib retraction, wheezing ● Transverse is twice as large as
- Test for skin turgor, pinch above clavicle
● Skin returned to normal immediately (or two seconds or less)
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Then palpate from side, just say it Feel down chest and under chest, ask women to lift breast or if you have to use the back of hand Use diaphragm left to right First one by clavicle, then upper middle of chest, then middle chest, then outer parts
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No pain or tenderness. No crepitus Lung sounds clear with inspiration and expiration in all lung fields
Respiratory symmetry - Use two hands and place at botton of rib cage, squeeze thumbs together with little skin between and have them take a breathe
● Symmetrical movement seen when taking a deep breathe.
Costovertebral angle tenderness - Tap hand on kidneys under ribs on bac
● No pain or tenderness with CVAT assessment
Cardiac
Task Documentation/verbalize findings
Inspection - Raise bed to 30 degree ● No moles, bruises, or cuts. Skin
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Inspect skin for bumps, rashes, lesions, bruises, moles Inspect palpitation (movement at chest) Inspect pulsations (base of neck) Inspect thrills (use outer part of hand and place on chest, feel for vibrations) Locate PMI (apical pulse, apex of heart)
color is pale and even throughout.
● Some pulsations seen. No palpitations seen. ● No thrills noted ● PMI is at the midclavicular line, fifth intercostal space. (where it is supposed to be)
auscultation - - - - - - -
Want to hear S1 and S2 (lub, dub) Apical pulse is diaphragm for full minute 1st (aortic):start with bell, right, second intercostal space, under clavicle 2nd (pulmonic), just move left 3rd (Erb’s): left atrial, second to fourth intercostal 4th (tricuspid): right atrial, 3rd to 5th space 5th (mitral): left ventrical, 2nd-5th space
● Stay in each cardiac area for 20- 25 seconds ● S1 S2 was auscultated in all cardiac areas. No S3 or S4 found. ● Apical pulse was ## for a full minute
Do everything with bell, then everything again with diaphragm
Abdomen
- Have them lay down and can put pillow under knees
- Inspect skin for bumps, bruising, lesions, moles, coloring, rashes, hernias around belly button, striae (stretch marks)
- Describe contour: flat, concave, round, protruding
- Inspect for pulsation
- Auscultate for bowel sounds Vascular sounds: use bell listening for bruits Hold 15 sec in each spot
- Aortic in center under sternum
- Renal on left and right outside
- Iliac on left and right by iliac bone
- Femoral on left and right
● Standing to right side of patient always ● Skin is intact. No bumps, bruises, scars, rashes, striae, or hernia seen. Moles are small, flat, and symmetrical in shape. No tattoos or piercings ● Flat abdominal contour ● Light pulsations seen
● Vascular Sounds: No bruits heard in all areas. (Aortic, Renal, Iliac, and Femoral) ● Bowel Sounds: ○ Active bowel sounds x present. ○ Hyperactive bowel sounds x4 (hear bowel sounds right away). ○ Or hypoactive bowel sounds x4 (takes a little bit
(verbalize)
- Don’t want to hear swooshing sound
- Bowel sounds: diaphragm
- Divide into four quads
- Start in right lower quad, go to upper right, then left upper, then lower left
- Active bowel sounds 4x (in all 4 quads)
- Hyperactive or hypoactive 4x
- Listen to entire belly for 5 min if not hearing anything Percussion:
- Checking for masses or obstruction
- Listen for tympany (hollow)
- Dullness ( solid organs)
- Put flat hand on abdomen and tap with other: start on right lower quad Palpation:
- Are you currently experiencing pain or tenderness or tell me if you feel that
- Start with one hand in right lower
- Then use two hand and feel for masses and pain or tenderness
- Verbalize feeling inguinal nodes (horizontal and vertical)
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longer to hear bowel sounds). ○ Absent bowel sounds (listen for 5 minutes or 1:30 in each quadrant and no sounds)
Ask when was last bowel movement and last menstrual cycle. Last time urinated. Tympany heard over hollow organs and dull heard over bone and solid organs. Light Palpation ○ To self: Does abdomen feel soft or hard. ○ Normal finding: Abdomen was soft to touch with light palpation Looking for rebound tenderness with appendix (RLQ) Deep palpation ○ Slight discomfort in left lower quadrant ○ No pain or tenderness in RUQ and RLQ with deep
Testicular -
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Do you know how to do your own testicular exam Do once per month and better after the shower and start looking for redness, edema, symmetry Palpate: place on top of middle finger and roll between thumb and
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Teach when patient says “no” No lumps, pain, or tenderness If you palpate any abnormality or lump contact your doctor. Have patient teach back to you
note abnormality or lumps
- Can you teach it back to me
211 Physical Assessment Steps
Course: Health Assessment (NSG 121)
University: Herzing University
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