Physical Assessment

Hair

Hair is clean, equally distributed and without alopecia, infestations or lesions

Scalp

Normocephalic with the scalp smooth and intact with no bumps, no indentations

Eyes and symmetrical

Bilateral ears are at appropriate level in relationship to bilateral eyes

Eyes

Bilateral ears are appropriate level in relationship to bilateral eyes

Eyes

PERRLA, six cardinal intact without nystagmus. Sclera white bilaterally conjunctiva pink bilaterally

Ears

Assess bilateral ears and perform voice/whisper test for hearing acuity bilaterally
- No excessive cerumen
- Client hearing intact bilaterally

Nose

Assess for midline septum and for drainage; assess smelling acuity
-No unusual drainage, no flaring of nostrils, no septal deviation noted
-Smelling intact, patient able to identify odors

Mouth

Assess lips, mucous membranes, teeth for any excessive decay or cavities, uvula placement
-Lips pink and intact
- Client has good indentation with no noted caries
- Oral mucous membrane pink and moist & uvula midline

Face

Check for symmetry, appearance, sensory perception, and facial nerves (smile, eyebrows, puffing cheeks)
-Face is symmetrical with no drooping
- Skin is smooth, intact with appropriate coloring
- Client able to identify fine touch
- Client able to smile, lift brows and puff cheeks without difficulty (facial nerves intact)

Assess lymph nodes, trachea, and swallowing. Assess for jugular vein detention

No enlarged lymph nodes, trachea midline, no difficulty swallowing, no jugular vein distention (JVD), no enlargement of thyroid noted

Skin turgor

Check over the sternum or below the clavicle
-less than 3 seconds snd without tinting

Shoulder shrug

Strong shoulder shrug bilaterally

Skin

Pink, warm, dry and intact to upper extremities bilaterally

Radial pulses

Radial pulses equal bilaterally

Hand grasps

Hand grips strong bilaterally

Capillary refill

Capillary refill less than 3 seconds to bilateral upper extremities

Aortic

2nd intercostal space to the right, S2 heard loudest

Pulmonic

2nd intercostal space to the left, S2 heard the loudest

Erb's point

3rd intercostal space to the left, S1 and S2 equal

Tricuspid

4th intercostal space to the left, S1 heard the loudest

Mitral

5th intercostal space to the left at the midclavicular line, S1 heard the loudest

Take apical pulse at the point of maximum impulse (PMI) for how long?

One full minute

While listening to apical pulse palpate radial pulse to check for pulse deficit

Apical pulse-apical pulse 70 with regular rhythm, no pulse deficit needed

Auscultate 10 sites to posterior chest
Auscultate 10 sites to anterior chest
Auscultate 4 sites to lateral chest bilaterally

(move the diaphragm from side to side from the top to the bottom of the lungs for anterior, posterior and lateral)
-Lungs clear to auscultation to all 5 lungs fields

Check thoracic excursion for symmetry (1-2 inches with inhale)

Chest expansion equal bilaterally

Assess spine

Spine midline with shoulders at equal height, no exaggerated curvature of spine noted

Drape client for what?

Dignity

3 questions: last bowel movement, any problems with urination or bowels, last menstrual period

Last bowel movement this morning; soft and formed
No difficulties with urination
Last menstrual period 1 week ago

Inspection

Abdomen flat, no noted scars, masses, striae or pulsations

Auscultation

Start in right lower quadrant and go in a clockwise direction (RLQ, RUQ, LUQ, LLQ)
-Bowel sounds present in all four quadrants
-If i hear no bowel sounds for 2-5 minutes would be reported as absent

Palpation

Palpate in some sequence as auscultation, note any facial grimacing during palpation
-Abdomen soft; no masses, pain, or tenderness

Hips

Check hips for crepitus
-no crepitus noted

Lower extremities

Lower extremities pink, warm, dry and intact bilaterally

Assess posterior calves

For any excessive warmth, erythema or discomfort; consider at risk for deep vein thrombosis (DVT)
-No excessive warmth, erythema, or discomfort to bilateral calves

Assess for edema

On anterior shins, ankles and top of feet (dorsal side) for 5 seconds in each spot bilaterally

Capillary refill

Capillary refill less than 3 seconds to bilateral lower extremities

Pedal pulses

Check simultaneously
-Pedal pulses present and equal bilaterally

Lower extremity strength

Assess muscle strength to bilateral lower extremities; resisting the push and resisting the pull
- Muscle strength equal and strong to bilateral lower extremities

Gait/mobility

Have client stand and walk for approximately 10 feet and return while assessing gait
-Steady gait noted