Comprehensive Nursing Physical Assessment Protocol

Flashcards covering the head-to-toe physical assessment procedure, vital signs, systemic physical exam findings, and health history screening questions based on lecture notes.

Initial Preparation and Safety Steps

The clinical entry workflow that includes following GBSP and 11 rights, knocking, checking the environment, introducing oneself, performing hand hygiene, providing privacy, verifying patient name and DOB via armband, checking for pain or allergies, and asking permission for a physical assessment while assessing for anxiety or SOB.

General Appearance Observation

Direct visual assessment stating that the patient is well groomed with a clean appearance and a body that appears symmetrical.

Baseline Vital Signs

Assessment baseline measurements recorded as BP 120/60, HR 80, RR 18, O2 98% on room air, and Temp 97.5.

Scalp and Head Inspection Findings

Assessment performed with gloved hands after hand hygiene showing the head is symmetrical with no lesions or swelling.

Ear Inspection Findings

Palpation and visual inspection showing no discharge and no foreign objects, accompanied by asking about hearing devices when no hearing aids are present.

Whispered Hearing Tests (EBL & RFG)

Hearing evaluation performed on the left ear (EBL) and right ear (RFG) by having the patient repeat phrases whispered to each side.

Facial Skin and Temperature Assessment

Evaluating skin temperature with the back of the hand on the forehead, confirming the face is pink, warm, symmetrical, with no lesions or facial hair.

Facial and Jaw Motor Assessment

Assessing head ROM, jaw movement (open, closed, clenched), resistance strength (pushing face and shoulders against hands), motor actions (sticking tongue out, pushing tongue against cheeks, smiling), and inspecting the throat while saying 'ahh'.

Oral Mucosa Findings

Inspection of the inside and outside of the mouth demonstrating oral mucosa that appears pink, moist, smooth, with no lesions or abnormalities.

Nose and Sinus Assessment

Palpating above the eyebrows, under the eyes, and down the nose, and testing patency by closing one nostril at a time to breathe; findings show no pain, no drainage, moist red mucosa, and no lesions or abnormalities.

Swallowing and Speech Assessment

Placing a hand on the throat while the patient swallows, confirming the patient swallows fine with no abnormalities and speech is clear.

Pupillary Light Reflex Findings

Dimming lights, shining a light into the eyes, and restoring room light; pupils appear equal, round, and reactive.

Cardinal Fields of Gaze and Visual Acuity

Testing extraocular movements using a pen light held 12 inches back and checking field of vision by having the patient read the smallest line on a chart, noting good vision without visual devices.

Olfactory and Tactile Facial Sensation Tests

Asking the patient to close their eyes to identify a scent (coffee) and report the location of light touch applied to their face.

Upper Extremity Pulse and Perfusion Assessment

Palpating carotid pulses on both sides, checking brachial pulses (bend of arms) and radial pulses (wrists) simultaneously, checking skin temperature, edema, capillary refill, and bilateral hand squeeze strength.

Lower Extremity Physical Assessment

With the head of the bed lowered, inspecting the legs, checking knee flexion/extension (ROM), palpating posterior tibial pulses (interior of ankles) and dorsalis pedis pulses (top of feet) with temperature, testing toe wiggling, capillary refill on toes, edema, and testing strength via pushing and pulling feet against hands.

Skin Turgor Inspection

Slightly pulling the gown down on the upper chest to assess turgor, confirming the patient appears well hydrated.

Cardiac Auscultation Protocol and Findings

Using a warmed stethoscope diaphragm to listen under the collarbone, sternum, and left/right side under the left breast, and using the bell at the far left side of the breast for 1 minute; findings show regular S1 and S2 with no abnormal sounds.

Anterior Lung Auscultation Protocol

Auscultating front lung fields during deep breaths, covering top chest edges under the collar (both sides), middle chest, even with nipples around sternum, and spreading wider to the sides.

Posterior Thorax and Posterior Lung Auscultation

Having the patient lean forward, assessing skin edema and sacral area, and listening to 20 deep breaths at 14 locations in a ladder pattern starting right below the neck on the outside and moving upwards along the sides of the back.

Abdominal Auscultation Protocol

Exposing the abdomen while supine, inspecting skin and pulses, and listening with the diaphragm for 1 minute in each quadrant in sequence: RLQ, RUQ, LUQ, and LLQ.

Vascular Bruit Auscultation

Auscultating the middle top of the stomach and both carotid arteries using the stethoscope bell while the patient holds their breath, confirming no bruits.

Abdominal Palpation and Percussion Protocol

Systematically feeling and percussing the abdomen starting in the RLQ following a directional grid.

Subjective Health History Screenings

Inquiring about past surgeries, allergies, pain, current medications/supplements/herbs, vaccines, income, living arrangements (living alone), feeling safe, reliable transportation, access to meds, mental health, and thoughts of self-harm or harming others.

Post-Assessment Closing Sequence

Informing the patient the doctor will be in shortly, placing the call light in hand, ensuring patient needs are met, performing hand hygiene, and proceeding to report and record documentation.