Physical Assessment

Initial Assessment

• Introduce seld- AIDET

• Hand Hygiene

• Ask about quesitons and concerns

• Note general appearance: are they dressed appropriately for the weather/situation? Well groomed or disheveled? How is their work of breathing? Relaxed, tense?

• Cognitive status: Orientation to person, place, time (month and year)

Head & Neck

• Inspect Face (General skin, feature symmetry): Do their features appear symmetrical? Is their skin color pale, flushed, cyanotic, jaundice, diaphroetic?

• Inspect scalp and hair: note skin integrity of scalp, hygiene, any lesions or infestations, hair texture, distribution, etc. Note any deformities or tenderness w/palpation (is there flaking, lice, is hair clean and evenly distributed?)

• Neck: inspect the skin color and integrity, trachea midline, palpate lymph nodes, and palpate for TMJ (any crepitus?)

• Test Facial Sensation w/cotton ball: CN 5- Trigeminal nerve

• Test shoulder shrug and head turn against hand: CN 11- spinal accessory

• Test facial mobility via raise eyebrows, frown, show teeth, puff cheeks: CN 7- facial

Eyes

• Inspect brows, lashes, lid position, and lid skin

• Inspect conjunctiva, iris, sclera (any tearing or drainage?)

• Assess EOMs (six cardinal positions of glaze): CN 3, 4, 6 (Oculomotor, trochlear, abducens), any nystagmus?

• Cover/Uncover test: any strabismus?

• Corneal Light Reflex: pt look up at light and light should reflect in the same spot (esotropia?)

• Assess PERRLA using pen light: Pupils equal, round, reactive to light and accommodation, CN 3- oculomotor

• Assess visual acuity w/snellen chart: L/r/Both, Cn 2- optic

Ears

• Ears: position, skin, assess for pain at pinna/tragus (pinna elastic? skin dry and intact? tenderness or discharge? symmetrical?)

• Whisper test: CN 8- vestibulocochlear

Nose

• Inspect external symmetry, skin, internal septum and membranes (symmetrical? deviated septum? skin dry and intact?)

• Asses smell and patency: CN 1- Olfactory

Mouth and Throat

• Inspect oral cavity: lips (chapped? intact? symmetirc?), buccal mucosa (moist and pink? lesions?), teeth (intact? white?), gums (pink and moist?), pharynx (pink and moist?), tonsils, dorsal and ventral surface of tongue (intact? lesions?)

• Test tongue movement: CN 12- hypoglossal

• Assess swallow, uvula rise w/ “aah”: Cn 9 and 10- glossopharyngelan and vagus (uvual and palate rise symmetrically?)

Posterior Thorax

• Inspect ease of breathing and skin, note AP diameter- 1:2 (breathing pattern: rhythm, effort, use of accessory muscles?)

  • Breathing: Normal = nonlabored and regular rhythm, Abnormal = shallow, fast, intercostal retractions, use of accessory muscles, pursed lip breathing, nasal flaring)

  • Skin: Normal = skin tone appropriate for ethnicity, Cyanosis = bluish skin/lips/nail bed, Pallor = loss of color, pale (is it clean, dry and intact?)

• Asses CVA tenderness

• Assess for symmetric expansion

• Auscultate posterior lung fields (8)

• Auscultate lateral lung fields (4)

• Identify lung sounds (mainly vesicular)

Anterior thorax

• Inspect skin (clean, dry and intact?)

• Auscultate top/anterior lung sound

• Identify lung sounds

• Palpate carotids and valves for thrills (evidence of thrills?)

• Name valves and landmarks

• Auscultate heart sounds w/bell and diaphragm (murmurs?)

• Ausculate carotid arteries w/bell (evidence of bruits?)

What are the places to listen and palpate for heart sounds?

1. Aortic valve: 2nd right intercostal space, right sternal border

2. Pulmonic valve: 2nd left intercostal space, left sternal border

3. Erb’s point: 3rd left intercostal space, left sternal border

4. Tricuspid valve: 4th left intercostal space, left sternal border

5. Mitral valve: 5th intercostal space, left mid-clavicular line

Where are SI and S2 heart sounds heard the best?

• S1: “lub”, sound of tricuspid and mitral valves closing, heard loudest at apex

• S2: “dub”, sound of aortic and pulmonary valves closing, heard loudest at base

Abdomen

• Inspect skin, contour, umbilicus (abdomen falt, rounded, protuberant?)

• Auscultate bowel sounds w/diaphragm x4 quadrants (hyperactive, active, hypoactive, absent? Borborygmus?)

• Auscultate w aorta w/bell (bruit?)

• Palpate 4x quadrants and center w/ light palpation (after listening) (any tenderness or masses palpated)

• Name organs w/ palpation

Peripheral Circulation

• Palpate bilateral pulses: Ulnar, Radial, Pedal, Posterior Tibial (equal?)

• Cap refill and edema: Upper and lower extremities

Musculoskeletal/Peripheral Neuro

• Bilateral ROM: neck, shoulders, elbows, wrist, fingers, hips, knees, ankles

• Inspect: arms and legs skin