Nursing Physical Assessment
Physical Assessment Lab 120-103 1. General Survey ! Level?! Awake & Alert a. Orientation to person, place, time? b. Ability to Communicate in full sentences with clear speech? c. Posture: upright and erect, shoulders level and symmetrical? d. Personal Hygiene: Clean & neat, no odor, dresses appropriately for the weather. 2. Integumentary System: a. Color: Uniform color – pink, tan, brown, olive. Slightly darker on exposed areas. There are normally no areas of bleeding, ecchymosis, or increased vascularity. No skin lesions should be present except for freckles, birthmarks, or moles, which may be flat or elevated. . Temperature: Warm and dry bilaterally. Hands and feet may be slightly cooler than the rest of the body. Skin surfaces should be non tender. (use back of both hands on patient’s forearms) c. Textures: Skin should feel soft/fine or coarse/thick. d. Turgor: When the skin is released, it should instantly recoil, no tenting. Best place to assess: Ant. ?Chest or abdomen. **Verbalize: I will integrate the integumentary system throughout the rest of the exam through checking and observing. 3. Head, Face, Neck a. Cranium: The head should be normocephalic, midline, and symmetrical.? . Scalp: The scalp should be white to light brown, shiny, intact, and without lesions or masses, flaking, or pidiculi (lice)? c. Hair: Pale blonde to black, thick or thin, curly or straight, coarse or fine, shiny or dull.? d. Frontal Maxillary Sinuses: Should be non palpable and non tender (must ask “did that hurt? ”) e. Cervical Lymph Nodes: Should be non palpable and non tender, non visible or inflamed. (Preauricular, postauricular, occipital, submental, submandibular, tonsillar, anterior cervical chain, posterior cervical chain, supraclavicular. e. Best place to assess: Ant. Chest or abdomen. **Verbalize: I will integrate the integumentary system throughout the rest of the exam through checking and observing. Physical Assessment Lab 120-103 f. Carotid Artery: Has visible pulsation (should be in front of the sternocleidomastoid muscle), palpable bilaterally (not at the same time!!! ), no bruits (soft blowing or wooshing sound from constriction of plaque) g. Temporal Artery: Should be palpable and equal bilaterally h. TMJ: Glides smoothly, no clicking or crepitus. i. Trachea: Midline, Thyroid: non palpable, non tender (ask) j.
Neck: ROM & Muscle Strength: Stand behind the patient, touch the chin to the chest, look up at the ? ceiling, move each ear to shoulder (without elevating the shoulder), turn head to each side to look at the shoulder. The Cervical spine’s alignment is straight, the head is held erect. Normal muscle strength allows for full, complete, voluntary joint ROM against both gravity and moderate to full resistance. Muscle strength is equal bilaterally. There is no observed involuntary muscle movement. Say: “full active ROM with no restrictions” k.
Thyroid: Palpation: have the patient lower the chin slightly in order to relax neck muscles. Place your thumbs on the back of the patient’s neck and bring the other fingers around the neck anteriorly to rest their tips over the trachea on the lower portion of the neck. Move the finger pads over the tracheal rings. Gently move trachea over to the side, then have patient swallow. Feel for any consistency, nodularity, or tenderness. 4. Eyes? a. Eyelids: Palpebral Fissure are symmetrical, no ptosis or lid lag.? b. Lacrimal Glands: Pale pink, patent, no excessive tearing, dryness, drainage, or edema.? . Eyelashes: Evenly distributed no ectropion no entropion.? d. Eyebrows: Even and equally bilateral? e. Conjunctiva: clear, pink, moist, without lesions? f. Sclera: white & intact? g. Cornea: Surface should be moist and shiny and without discharge, cloudiness, opacity, and irregularity.? h. Iris: round, symmetrical, and colored: green, blue, brown, hazel, violet, honey, etc.? i. Pupils: PERRLA (Pupils are Equal, Round, Reactive to Light and Accommodation) Check pupil reflexes. check twice each eye, direct/consensual, then bring penlight toward nose to assess for accommodation. . Ears? a. Pinna: Non tender, symmetrical bilaterally, without lesions or masses, (top of pinna should always be equal to outer canthus) – palpate simultaneously? b. Tragus: non tender, without lesions? c. Mastoid Process (piece of bone inferior posterior ear): non tender, no swelling, equal bilaterally (if one is different, ask for how long)? d. Tympanic Membrane: Pearly gray, shiny, intact (sometimes will see some white-cottage cheese looking bumps = scarring) MAKE SURE TO CHANGE SPECULUM BTWN EARS FOR PRACTICUM Adult: pull back and up, look anterior.
Child pull down) **know how to use equiptment!! Instructors/proctors look for this!!! *** e. Umbo: (Part of the Stapes) Make sure this is present, Protruding = dehydrated, Not present = fluid behind eardrum. f. Cone of Light: Tiny triangle anterior inferior on tympanic membrane = healthy. 5:00 on the right ear, 7:00 on the left ear. Physical Assessment Lab 120-103 6. Nose? a. Nares: patent, have patient occlude one nostril and gently blow out air on back of hand to test patency. Mucosa: pink, moist, without lesions, edema, drainage? b. Septum: without deviation.
Best was to assess is to push tip of nose up – shows if deviation is present. ! ***If nares are pink = allergies. If nares are bright red = cold. Saline shortens cold as it washes it ! down to stomach, where stomach kills the virus. 7. Mouth/Lips? a. Lips: pink, moist, intact, without lesions? b. Teeth: 32 including 4 wisdom. White with good repair, without caries? c. Tongue: pink, moist, papillae intact, midline, full mobility (ask pt to stick tongue out move left, right, up, down), without lesions? d. Oral Mucosa: pink, moist, without lesions (use tongue depressor & penlight) no red, no swelling? . Gingiva: pink, moist, intact, no bleeding? f. Uvula: Midline, rises symmetrically with soft palate when patient says “Ahhh” If absent patient will be sensitive to gagging. If long may be a sign of sleep apnea? g. Tonsils: Pink, symmetrical. They are graded from “absent – +4) +1 = peeking, +4 = kissing h. Hard/Soft Palate: pink, intact. Soft palate is pinker than hard Write: “What you would expect to see” If not, must state what you see. Are the eyelids covering the top of the iris? Always compare OD to OS. First begin assessment with visual acuity.?
Corneal Light Reflex: Shine penlight 12-15” away toward eyes (at midline) Should get right reflex in same position in each eye. If asymmetric they have strabismus (weak eye muscle) Ears: Use tuning fork? Weber Test: Hit on palm Hold at tip head (hairline) Should be able to hear equally in each ear. Rinne Test: hearing acuity. Hit prongs on palmar, put it on mastoid process until can’t hear it any longer, then move it to holding it in front of the ear canal. ***Air conduction should be twice as long as bone conduction*** Semicircular Canals: control balance and equilibrium
Vertigo can be caused by a foreign body which has been dislodged and landed in semicircular canals. Native Americans and Asians can have “Torus Palantitis” looks like mountain ranges on palate this is a benign condition. 8. Sensory Neuro (answer to most cranial nerve testing is “intact”) *verbage: Physical Assessment Lab 120-103 a. Sensation – light touch, sharp/dull, intact? a. Upper Extremities – use cotton ball, & sharp & dull sides of broken tongue depressor use 3 spots: finger, back of hand, arm. * ! b. Abdominal Reflex * ! ! Positive or not present * ! . Lower Extremities – use cotton ball & sharp & dull sides of broken tongue depressor use 3 spots: toe, top of ! foot, and shin.? b. Deep Tendon Reflexes – (smack deep tendons using flat side of hammer) *These are graded 0-4 “What you would expect to find +2/4”) ? a. Biceps – place thumb at patient’s elbow (antecubital) to hold their arm. Hit own thumb with the hammer. ?b. Triceps – hold patient’s muscle so patient’s arm can swing freely. Hit hammer above funny bone. ?c. Brachial Radialis – Hold pt’s hand then hit hammer midway btwn wrist & antecubital. d.
Patellar – Find tendon right above patellar bone, hit hammer on tendon? e. Achilles – About 2” above heel, support foot, relax leg. Will have plantar flexion.? f. Plantar or Babinski ?????????? = severe brain damage “abduction”. So we say “Positive plantar ? flexion, no abduction” ?????????? we only expect to find in babies. How to test: use metal side of hammer and trace the outer margin of the foot and across top, under toes. ?babinski or ????????? f. Best place to assess: Ant. ?Chest or abdomen. **Verbalize: I will integrate the integumentary system throughout the rest of the exam through checking and observing.