Nursing 211 – Introduction to Therapeutic Nursing Interventions

Physical Assessment Guidelines and Format

 

  1. Videotape your performance of a physical assessment of an adult (other than a classmate).  Use the assessment format provided.

 

  1. Document the results of your assessment using appropriate terminology.  Remember to be clear, concise, complete and correct.

 

  1. Your documentation and self-evaluation are to be typed and submitted with your videotape by the assigned due date.

 

  1. You are to review your videotape and complete a self-evaluation of your assessment.  Your self-evaluation is to be attached to your assessment documentation.  Evaluate your:
    1. Communication skills with the client.
    2. Organization of the assessment
    3. Strengths
    4. Areas for improvement

     

  1. Your performance exam and documentation will be evaluated as satisfactory or unsatisfactory.  Satisfactory indicates:
    1. All items performed correctly
    2. Exam completed within 30 minutes
    3. Documentation is concise, complete and correct.

  

     6. An unsatisfactory may result in failure of the course.

 

II.      Components of Examination

Comments

A. Initial Impressions/General Survey
Some initial impressions of your client can be made by using the skill of observation.  After introducing self, note:
  1. Gender and Race
  2. Signs of distress-physical/emotional
  3. Posture/gait/body movements
  4. Age
  5. Hygiene/grooming/dress
  6. Body odor
  7. Affect and mood
  8. Speech
  9. Weight/height

Measure vital signs, including temperature, radial pulse, respirations, and blood pressure.

 

 B. Skin/Hair/Nails
 Inspect and Palpate Skin
  1. Color-pigmentation, signs of cyanosis, pallor, erythema, jaundice.
  2. Moisture-oily, wet, crusting, flaking, itching
  3. Temperature-assess extremities, wounds
  4. Texture-smooth or rough, thin or thick, tight or supple, indurated or soft.
  5.  Turgor-skin elasticity assessed by pinching skin over sternum or forehead.  Pinching skin on back of hand may not be accurate measure of dehydration in older adult.
  6. Vascularity-Look for petechiae, reddened, pink, or pale skin on pressure areas.
  7. Odor
  8. Lesions-determine if:
      a.   normal (freckles)
      b.  age-related (senile keratosis or skin tags)
      c.   abnormal-describe color, location, size, appearance, shape, stage, type, and exudates, sensations.
      d.  Incisions/scars-describe as above

Inspect hair and scalp: color, distribution, unusual findings

Inspect Nails: color, smoothness, cleanliness, odor

 

 

C. Head and Neck
  1. Head and Face (inspection, palpation, percussion)
      a.  Skin characteristics
      b.  Skull configuration
      c.   Hair quality and distribution
      d.  Frontal and maxillary sinuses (palpate and percuss)
      e.   Facial movement; whistle; frown; smile; puff out cheeks.
  2. Eyes (inspection and palpation)
      a.   Visual acuity (CN II)
      b.  Brows, lids, conjunctiva, sclera, lacrimal ducts
      c.   Extraocular movements III, IV, VI; 6 positions gaze test
      d.  Pupillary response to light and accommodation
      e.   Ophthalmoscopic exam of lens (red reflex)
      f.    Cover/Uncover test
  3. Ears (inspection & palpation)
      a.   External ear
      b.  Auditory acuity (CN VIII)
      c.   Otoscopic Exam-ear canal & tympanic membrane                                                                          4. Nose (inspection and palpation)
      a.   Patency
  5. Mouth and Pharynx (inspection and palpation)
      a.   Lips, mucosa, teeth, gums, tongue
      b.  Tonsils, uvula, swallowing (CN IX & X)
  6. Neck (inspection and palpation)
      a.   Lymph nodes
      b.  ROM 

 

D. Thorax and Lungs-Anterior and Posterior (inspection, palpation and auscultation)
  1. Skin characteristics
  2. Alignment and configuration
  3. Lung expansion
  4. Auscultation-posterior, lateral, anterior 

 

E. Heart (Inspection, palpation, & auscultation)

  1. Inspect thorax
  2. Palpate PMI
  3. Auscultate 5 areas: aortic, pulmonic, Erb's point, tricuspid, apical

 

F. Abdomen (inspection, auscultation and palpation)
  1. Inspect skin, contour, pulsation
  2. Auscultate bowel sounds
  3. Light palpation for tenderness
  4. Deep palpation for masses (place client in correct position)

 

G. Musculokeletal/Peripheral Vascular (inspection and palpation)

  1. Lower Extremities
      a.   Skin, muscle mass, alignment
      b.  Temperature, edema, capillary refill, joints
      c.   Palpate pulses-dorsalis pedis, posterior tibial
      d.  ROM & strength hip, knees, ankles
  2. Upper Extremities
      a.   Inspect skin, muscle mass, alignment
      b.  Palpate temperature, capillary refill, edema, joints
      c.   Palpate pulses-brachial, radial, ulnar
      d.  ROM & strength-shoulders, elbows, wrists, fingers.
3. Spine (cervical, thoracic, lumbar)
alignment ROM

 

H. Neurologic (inspection, palpation)

  1. mental status
  2. cranial nerves
      a.   PERRLA
      b.  Eom's
      c.  facial movements
  3. motor
      a.   muscle size and strength
      b. gait
      c. Romberg
      d. heel to toe walking
4.  sensory
      a. light touch

5.DTRs--biceps, triceps, patellar, Achilles, plantar.

 

I. Breast or Testicular Self Exam Patient Education

  1. Assess client’s practice of self exam
  2. Assess knowledge of proper technique
  3. Correct errors/provide information of self exam
  4. Evaluate client’s understanding of correct self-exam.

 

 

III. Recording

Comments

Clearly, concisely, legibly
Pertinent information included
Appropriate anatomical-physiological terms used.

 

    

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