Physical Assessment

Provide Patient Privacy

Wash hands per CDC guidelands. Don clean gloves

Introduce yourself

dentify patient correctly using two identifiers (check to chart & armband).

Verify allergy status

Perform environmental safety check (bed lowest, floor clear, suction, yaunker, oxygen, ambu bag)

Ensure proper body mechanics

Educate patient and explain procedure

General Survey

Assess level of consciousness: Alert & Oriented x 4 (person, place, time, situation)

Assess overall demeanor of patient: Mood/affect, personal hygiene

Assess communication: Speech (slurred), able to articulate, hearing (Hearing aids or HOH), vision (difficulty

seeing, blurred vision, double vision)

Pain: Perform pain assessment (PQRST) utilizing 0-10 scale, or other pain tool as appropriate for patient

Head and Neck

nspect: Head for bumps, if needed – check hair distribution, infestations and skin integrity

Inspect: Ears for drainage, placement, tenderness and any abnormalities

Inspect: Face – check for symmetry – facial droop, color (pale, flushed, jaundice)

Inspect: Eyes - redness, discharge – contacts, glasses, sclera, extra ocular movements, pupil size, PERRLA

Inspect: Nose – overall condition, any drainage, patency (if applicable)

Inspect: Mouth and gums for moisture, cracked lips, bleeding gums, tongue (swollen), can patient swallow, do

they wear dentures, does the tongue move appropriately, breath odor

Inspect: Neck – swollen lymph nodes – note size and location if present, JVD (at a 45 degree angle), goiter,

deviated trachea

Palpate: Head (sinuses) or neck (lymph nodes) if obvious abnormalities present

Ask: Facial sensation, ability to smell

Skin

Inspect: Skin for breakdown – (ears, nares, elbows, shoulders, hips, knees) note location and descriptors if present

nspect: Color –cyanotic, bruising, pale, jaundice, mottled

Palpate: Skin for temperature – use dorsal part of hand – cool, clammy, hot, dry

Palpate: Turgor (under clavicle)

Braden Scale: Complete and document pressure ulcer risk assessment as indicated

Upper extremities

UPPER EXTREMITIES

Inspect: ROM, symmetry of extremities, able to perform ADL’s, shoulders raise and lower, joints stiff or swollen,

nails pink, no clubbing noted

Palpate: IV Site for tenderness and warmth if applicable

Palpate: Radial, brachial, ulnar pulses bilaterally – check for deficit, +1, +2, +3, absent

Palpate: Muscle strength in hands (check bilaterally) and grade on 0-5 scale

Palpate: Capillary refill in fingers - < 3 seconds or > 3 seconds

Thorax, Heart, and Lungs

Inspect: Thorax (chest cavity), symmetry, bruising, surgery scars, inspiration, expiration, use of accessory muscles

Palpate: Chest wall for tenderness if indicated; palpate for implanted device (port-a-cath, pacemaker, etc.)

Auscultate: Heart sounds Apical (PMI) – check for 1 minute

Auscultate: Anterior lung fields in 6 places (including laterals)

Ask: Tobacco use or other substances, respiratory conditions, cough, mucus production, use of 02

Back

Inspect: Position of spine, bruising scaring, skin breakdown (includes the sacrum/coccyx)

Palpate: Back for tenderness including costovertebral if indicated

Auscultate: Posterior lungs fields in 8 places including bases (avoid bone)

ABDOMEN (GASTROINTESTINAL) (GENITOURINARY)

Inspect: Abdomen for bulging masses, distention, bruising, tubes or drains, scars

Auscultate: Bowel sounds in 4 quadrants – start in RLQ for hypo, hyper or normal

Percuss: Abdominal quadrants for dull or tympanic sounds if indicated

Palpate: Abdominal quadrants for masses or tenderness if indicated

Ask: Presence of nausea/vomiting, difficulty eating, last BM (was it normal for patient – frequency/consistency)

Inspect: Perineal area for skin breakdown, presence of foley catheter, and overall cleanliness

Ask: Presence of pain with urination, blood in urine, dark colored urine, foul odor, frequency, hesitation or

burning with urination

LOWER EXTREMITIES

Inspect: Legs for symmetry, ROM, muscle strength, hips for stiffness and/or pain, skin for color, temp, bruising,

and skin breakdown, hair distribution

Inspect: Calves for heat, redness, swelling

Inspect: Feet – overall condition, heels/ankle for skin breakdown, nails

Palpate: Edema (pitting vs. non-pitting)

Palpate: Dorsalis pedis, post tibial and if needed popliteal pulses bilaterally +1, +2, +3, absent

Palpate: Capillary refill in toes – <3 seconds or > 3 seconds

Ask: Ability to ambulate, use of assistive devices, and if there are any difficulties with gait (Romberg test if

indicated

Safety Risks

(NPSG) Ask: Suicidal Ideations (Do you have a plan to hurt yourself, or others)

Morse Fall Scale: Complete and document fall risk assessment as indicated

ABUSE

Ask: History of abuse (Do you feel safe here, or at home)

Ensure safe environment: bed to appropriate height, brakes locked, appropriate side rails up and

call light within reach.

Remove gloves. Wash hands per CDC guidelines.