Medicine

36. Complete Physical Examination

COMPLEATE PHYSICAL EXAMINATION

Clinical Setting

n Cleanliness

n Safety – standard precautions, transmission based precautions

n Warm, quiet, private environment

n Good lighting

n Equipment ready

n Explain what you are doing

n Make slow movements

n Organize steps of assessment to prevent unnecessary position changes

A health assessment is a judgment of physical, mental and quality standards of a person's life. It is most often conducted by a medical office and it is often given to elderly people. A health assessment may also be done by insurance companies or employers, looking to review an employee's overall health. Each medical institution uses its own scoring and scale of good health. You will want to judge both the appearance of health, the need of assistance and the person's pain or feeling during the activity. You should decide upon the difficulty and pain scale before performing the health assessment. For example, some people use words to describe pain while other people use a scale of between 1 and 10, with 10 being the worst. This article will tell you how to do a health assessment.

Method 1 of 5: Physical Assessment

Ask the person to complete a questionnaire that lists any symptoms that they have experienced in the last week to 6 months, as defined by your facility.This should be a standard questionnaire that requires a patient to check certain boxes and allows the person space to write recent procedures.

These symptoms should include musculoskeletal, ears, nose, throat, head, chest, lungs, heart, neurological, psychological, gastrointestinal and dermatological.

Ask the person to list their current medications. Then, ask your patient to rate their general pain on a scale that you have decided upon. This will mean more in a medical, than an employment, test.

Perform a physical examination of the person if you are a doctor. This can include a blood test for cholesterol, insulin and blood cell levels, or a pap smear if you are a woman. Also, take the height, weight, pulse and other measurements as required of a yearly physical examination.

Test the vision, hearing, chest and lungs of the person with medical instruments. You will need a stethoscope and other instruments to ensure these functions are accurate. Only a doctor should perform these elements of the physical health assessment.

Test the mobility of the person in question. Test their walking ability by checking if they are able to walk unassisted from room to room. Note any problems with walking and ask the person if this causes pain on a scale of your choosing.

Follow the walking test with a walking test up and down a small flight of stairs. Ask the person if this causes pain on a scale of your choosing.

See if the person is able to walk unassisted outside a household. Ask if they are able to perform the tasks needed to get ready to leave the house and walk on uneven ground. They may or may not need assistive technology, such as a cane or a walker.

Test the balance of the person. You can do this in a number of ways. The most common ways are asking the person to stand on 1 foot for 30 seconds and then the other, and to ask them to walk on their toes and then on their heels.

Method 2 of 5: Nutrition Assessment

Ask if medical illness or depression has left them with an inability to shop or provide meals for themselves. This will not be essential in all cases, and it may need to be done with some delicacy.

You may choose to take the person's Body Mass Index (BMI), which is the person's weight in kg divided by the square of their weight in m. If the person has lost 10 lbs. (4.5 kg) since a recent visit, it may also be seen as a problem with nutrition

Method 3 of 5: Self-Care Assessment

Ask if the person is able to bathe daily, dress, go to the bathroom by themselves and groom daily. These questions are essential amongst those in the elderly age bracket and should be rated on a scale of difficulty.

You may choose either a scale of numbers or words, such as "with no difficulty," "with some difficulty" and "with great difficulty."

Identify if the person is able to take care of their household affairs, or Activities of Daily Living (ADL). The following are household affairs that the person should rate the difficulty of completing, and if they are not properly able to complete them, a caretaker should be notified.

Doing the laundry and washing the dishes and doing other household cleaning and chores.

Managing household finances, from grocery and electric bills to taxes.

Taking medications as directed by a doctor, as well as arranging for transportation to all appointments and/or work.

Method 4 of 5: Mental Assessment

Ask the person if they are experiencing any symptoms of anxiety or depression. Although they may have filled out this information in their questionnaire, you may be able to bring to light feelings of loss, low self-esteem, lower functionality in daily life or other symptoms.

Perform a memory test, such as the Folstein Mini-Mental State Examination (MMSE). This may be a series of tests designed to detect dementia or delirium. Any mental health tests should be well-established as viable ways to detect memory loss or loss of mental function.

Test the person's executive function. This is the ability of the person to respond to new stimuli or a change in plans. One of the easiest ways to test this function is to ask the person to name as many 4-legged animals as they can in 1 minute.

Being able to list fewer than 8 animals or repeating animals is seen as a call for further memory testing.

Ask the person to explain their social network, including any friends or family that give support. You should discuss the financial needs for support by any government agencies and discuss the need for a caregiver.

Method 5 of 5: Results

Gather all of the information that was given through the tests and rate it on the agreed upon health scale. Not all aspects of this test may be essential for your health assessment. It is important that you agree upon a plan to see the person for a follow up, whether it is a doctor's appointment in a year, an insurance quote or a plan to see a specialist or caregiver.

Tips

A health assessment with the elderly is often called a comprehensive geriatric assessment (CGA). In this assessment, all aspects of life, including mental, physical, lifestyle and social health are tested in order to create a life plan. The plan should work toward increasing comfort, managing pain and overall improving quality of life.

Another test that is often associated with vision and mobility is a driver's test. Many older people may be required to take both a written and practical driving test to show that they are still capable of making quick decisions on the road.

A health assessment can be given by a doctor, a care giver, a social worker, or even a physical or occupational therapist. Each facility should decide what aspects will be assessed before beginning the process with patients.

PROCEDURE CHECKLIST

Assessing Body Temperature

Check (ü)Yes or No

PROCEDURE STEPS

Yes

COMMENTS

1. Selects appropriate site and thermometer type.

2. “Zeroes” or shakes down glass thermometer as needed.

3. Inserts thermometer in sheath or uses thermometer designated only for the patient.

4. Inserts in chosen route/site.
a. Oral: Places thermometer tip under the tongue in the posterior sublingual pocket (right or left of frenulum). Asks patient to keep lips closed.
b. Rectal: Lubricates thermometer; uses rectal thermometer; inserts 1 to 1.5 inches (2.5–3.7 cm) in an adult; 0.9 inches (2.5 cm) for a child, and 0.5 inch (1.5 cm) for infant.
c. Axillary: Dries axilla; Places thermometer tip in the middle of the axilla; lowers patient’s arm.
d. Tympanic membrane: Positions the patient’s head to   one side and straighten the ear canal.
   1) For an adult, pulls the pinna up and back.
   2) For a child, pull the pinna down and back

5. Leaves glass thermometer recommended time (oral 3–5 min, rectal 2 min, axillary 6–8 min).

6. Holds rectal thermometer securely in places; does not leave patient unattended.

7. Leaves electronic thermometer until it beeps.

8. Reads temperature. Holds glass thermometer at eye level to read.

9. Shakes down (as needed) and cleans or stores thermometer.

Recommendation: Pass ______ Needs more practice ______

Student: Date:

Instructor: Date:

PROCEDURE CHECKLIST

Assessing for an Apical-Radial Pulse Deficit

Check [ü] Yes or No

PROCEDURE STEPS

Yes

COMMENTS

1. Selects, correctly locates, and palpates apical site (5^th intercostal space at the midclavicular line).

2. Obtains another nurse to assist.

3. Places watch so it is visible to both nurses.

4. One nurse palpates radial pulse; the other uses diaphragm of stethoscope to auscultate the apex. Correctly locates sites.

5. Counts for 60 seconds.

6. Notes rate, rhythm, and quality.

7. Identifies S1 and S2 heart sounds.

8. Correctly obtains pulse deficit (apical rate minus radial rate).

Recommendation: Pass _____ Needs more practice _____

Student: Date:

Instructor: Date:

PROCEDURE CHECKLIST

Assessing Peripheral Pulses

Check (ü) Yes or No

PROCEDURE STEPS

Yes

COMMENTS

NOTE: You can use this checklist to evaluate one peripheral pulse, or to evaluate the student’s ability to locate all the peripheral pulses.

Circle site used:

radial, brachial, carotid, temporal, popliteal, femoral,

posterior tibial, dorsalis pedis

1. Selects, correctly locates, and palpates site.

2. Uses fingers (not thumb) to palpate.

3. Counts for 30 sec. if regular; 60 sec. if irregular.

4. Notes rate, rhythm, and quality.

5. Compares bilaterally.

6. Carotid pulse: Palpates only on one side at a time.

7. Correctly locates the following sites:
a. radial

b. brachial

c. carotid

d. temporal

e. popliteal

f. femoral

g. posterior tibial

h. dorsalis pedis

Recommendation: Pass _____ Needs more practice _____

Student: Date:

Instructor: Date:

PROCEDURE CHECKLIST

Assessing Respirations

Check (ü) Yes or No

PROCEDURE STEPS

Yes

COMMENTS

1. Flexes patient’s arm and places patient’s forearm across chest, or otherwise counts unobtrusively.

2. Counts for 30 seconds if respirations regular; 60 seconds if irregular.

3. Observes rate, rhythm, and depth.

Recommendation: Pass _____ Needs more practice _____

Student: Date:

Instructor: Date:

PROCEDURE CHECKLIST

Assessing the Abdomen

Check (ü) Yes or No

PROCEDURE STEPS

Yes

COMMENTS

1. Has the client void prior to the exam.

2. Positions the client supine with the knees slightly flexed.

3. Examines abdomen in this order: inspection, auscultation, percussion, palpation.

4. Inspects the abdomen for:
a. Size, symmetry, and contour.

b. Has client raise his head to check for bulges.

c. If distention is present, measures girth at umbilicus with tape measure.

d. Observes the condition of skin and skin color; lesions, scars, striae, superficial veins, and hair distribution.

e. Notes abdominal movements.

f. Notes position, contour, and color of the umbilicus.

4. Auscultates the abdomen for bowel sounds, using diaphragm of stethoscope.

a. Listens for 5 min. before concluding that bowel sounds are absent.

b. Uses stethoscope bell to listen for bruits.

c. Listens for bruits over aorta and renal, femoral, and iliac arteries.

5a. Uses indirect percussion to assess at multiple sites in all four quadrants.

5b. Estimates size of liver, spleen, and bladder.

6. Uses fist or blunt percussion to percuss the costovertebral angle for tenderness.

7. Palpates abdomen:

a. Begins with light palpation then uses deep palpation to palpate organs and masses.

b. For light palpation, presses down 1–2 cm in a rotating motion. Identifies surface characteristics, tenderness, muscular resistance, and turgor.

8. Palpates liver:

a. Places right hand at the client’s midclavicular line under and parallel to the costal margin.

b. Places left hand under the client’s back at the lower ribs and pressing upward.

c. Asks client to inhale and deeply exhale while pressing in and up with the right fingers.

9. Palpates spleen by:

a. Stands at client’s right side.

b. Places left hand under costovertebral angle and pulls upward.

c. Places right hand under the left costal margin.

d. Asks client to exhale and presses hands inward to palpate spleen.

Recommendation: Pass _____ Needs more practice _____

Student: Date:

Instructor: Date:

PROCEDURE CHECKLIST

Assessing the Anus and Rectum

Check (ü) Yes or No

PROCEDURE STEPS

Yes

COMMENTS

1. Inspects the anus, noting condition of the skin and presence of lesions.

2. Palpates the anus and rectum.

a. For women: Changes gloves to prevent cross-contamination. Inserts a lubricated index finger gently into the rectum. Palpates the rectal wall noting masses or tenderness.

b. For men: Has the client bend over the exam table or turn on his left side if recumbent. Inserts a lubricated index finger gently into the rectum. Palpates the rectal wall noting masses or tenderness.

3. Tests any stool on the gloved finger for occult blood. (For reference, go to Procedure Checklist Chapter 28: Testing Stoll for Occult Blood.)

Recommendation: Pass _____ Needs more practice _____

Student: Date:

Instructor: Date:

PROCEDURE CHECKLIST

Assessing the Apical Pulse

Check (ü) Yes or No

PROCEDURE STEPS

Yes

COMMENTS

1. Selects, correctly locates, and palpates apical site (5^th intercostal space at the midclavicular line).

2. Uses diaphragm of stethoscope.

3. Counts for 60 seconds.

4. Notes rate, rhythm, and quality.

5. Identifies S1 and S2 heart sounds.

Recommendation: Pass _____ Needs more practice _____

Student: Date:

Instructor: Date:

PROCEDURE CHECKLIST

Assessing the Breasts and Axillae

Check [ü] Yes or No

PROCEDURE STEPS

Yes

COMMENTS

1. Inspects the breasts, nipples, areola, and axillae for skin condition, size, shape, symmetry, and color. Notes hair distribution in axillae.

2. Inspects with client in these positions:

a. Sitting, arms at sides.

b. Sitting, arms raised overhead.

c. Sitting, hands pressed on the hips.

d. Sitting and leaning forward.

e. Supine with a pillow under the shoulder of the breast being examined.

3. Compares breasts bilaterally.

4. Inspects nipples for discharge; if present, obtains a culture.

5. Uses fingerpads of the 3 middle fingers to palpate the breasts using the vertical strip method, pie wedge, or concentric circles.

· Vertical strip method:

Starts at the sternal edge and palpates the breast in parallel lines until reaching the midaxillary line. Goes up one area and down the adjacent strip (like “mowing the grass”).

· Pie wedge method:

This method examines the breast in wedges. Moves from one wedge to the next.

· Concentric circles method:

Starts in the outermost area of the breast at the 12 o’clock position. Moves clockwise in concentric, ever smaller, circles.

5a. Does not remove fingers from skin surface while palpating; moves by sliding fingers along the skin.

6. Palpates the nipples and areola.

a. Notes tissue elasticity and tenderness.

b. Squeezes nipple gently between thumb and finger to check for discharge.

· c. If open lesion or nipple discharge is present, wears procedure gloves to palpate the breasts.

7. Palpates axillae and clavicular lymph nodes.

a. Patient sitting with arms at sides, or supine.

b. Uses fingerpads and moves fingers in circular fashion.

c. Palpates all nodes: central, anterior pectoral, lateral brachial, posterior subscapular, epitrochlear, infraclavicular, supraclavicular.

Recommendation: Pass _____ Needs more practice _____

Student: Date:

Instructor: Date:

PROCEDURE CHECKLIST

Assessing the Chest and Lungs

Check [ü] Yes or No

PROCEDURE STEPS

Yes

COMMENTS

1. Assesses respirations by counting the respiratory rate and observing the rhythm, depth, and symmetry of chest movement.

2. Inspects the chest for AP: lateral diameter, costal angle, spinal deformity, respiratory effort, and skin condition.

3. Palpates trachea with fingers and thumb.

4. Palpates the chest.

a. Palpates for tenderness, masses or crepitus.

b. Places hands on chest wall: anterior, posterior, and lateral.

5. Palpates chest excursion.

a. Places hands at the base of the chest with fingers spread and thumbs about 2 inches (5 cm) apart (at the costal margin anteriorly and at the 8^th to 10^th rib posteriorly).

b. Presses thumbs toward the spine to create a small skinfold between them.

c. Has the client take a deep breath and feels for chest expansion.

6. Palpates chest for tactile fremitus.

7. Percusses chest.

a. Percusses over intercostal spaces rather than over bones.

b. Uses indirect method of percussion.

c. Percusses anterior, posterior, and lateral.

d. Compares right side to left side.

8. Percusses diaphragmatic excursion

a. Percusses diaphragm level on full expiration; marks level.

b. Percusses diaphragm level on full inspiration; marks level.

c. Measures distance between the two marks.

9. Auscultates the chest.

a. Using same pattern as for percussion.

b. Using diaphragm of stethoscope.

c. Has client take slow, deep breaths through his mouth while listening at each site through one full respiratory cycle.

10. Auscultates for abnormal voice sounds if there is evidence of lung congestion. Correctly uses one of the following methods, following the same pattern as for auscultation:

a. Assesses for bronchophony by having the client say “1, 2, 3” as nurse listens over the lung fields.

b. Assesses for egophony by having client say “eee” while listening over the lung fields.

c. Assesses for Whispered Pectoriloquy by having client whisper “1, 2, 3” while listening over the lung fields.

Recommendation: Pass _____ Needs more practice _____

Student: Date:

Instructor: Date:

PROCEDURE CHECKLIST

Assessing the Ears and Hearing

Check (ü) Yes or No

PROCEDURE STEPS

Yes

COMMENTS

1. Inspect the external ear for placement, size, shape, symmetry, drainage, lesions, and color and condition of skin.

2. Palpate the external structures of the ear for condition of skin and tenderness.

3. Using otoscope, inspects tympanic membrane and bony landmarks.

a. Uses correct size speculum.

b. Has patient tilt head to side not being examined.

c. Looks for foreign object in canal before inserting scope.

d. For Adult: Pulls helix up and back.

For Preschool Child: Pulls helix down and back.

e. Inserts speculum slowly, only into outer 1/3 of canal.

f. Identifies location of cone of light and bony landmarks.

g. Uses “puff” of air to test TM mobility.

4. Tests gross hearing.

a. Stands 1 to 2 feet behind the patient. Has the patient cover one ear as you whisper some words. Repeats on the other side. Has the patient repeat the words heard.

b. Has the patient occlude one ear. Holds a ticking watch next to the patient’s unobstructed ear. Slowly moves it away until the patient says he can hear the sound.

5. Performs Weber test (places vibrating tuning fork on top of patient’s head, identifying as positive if sound not heard equally in both ears).

6. Performs Rinne test if Weber is positive.

a. Strikes a tuning fork on the table. While it is still vibrating, places it on the patient’s mastoid process.

b. Measures the time in seconds that the patient hears the vibration.

c. Moves the tuning fork to 1 inch (2.5 cm) in front of the ear and measure the time until the patient can no longer hear the vibration.

d. Compares AC and BC times.

7. Performs Romberg test: Has client stand with feet together, hands at side with eyes opened and then with eyes closed. Notes ability to maintain balance. Identifies swaying as positive Romberg.

8. Compares bilaterally throughout examination.

Recommendation: Pass _____ Needs more practice _____

Student: Date:

Instructor: Date:

PROCEDURE CHECKLIST

Assessing the Eyes

Check (ü) Yes or No

PROCEDURE STEPS

Yes

COMMENTS

1. Assesses distance vision using a Snellen chart.

a. Chooses correct chart for age and literacy.

b. Allows client to wear corrective lenses for test.

c. Has patient stand 20 ft from chart and cover one eye at a time.

d. Tests eyes singly and then together.

e. Records findings correctly.

2. Tests near vision by measuring the ability to read newsprint at a distance of 14 inches (35 cm). Correctly identifies hyperopia or presbyopia if present.

3. Tests color vision by using color plates or the color bars on the Snellen chart.

4. Assesses peripheral vision by determining when an object comes into sight.

a. Seats client 2 to 3 feet from nurse

b. Has client cover one eye and gaze straight ahead.

c. Begins well outside normal peripheral vision and brings object to the center of the visual fields.

d. Repeats in all 4 visual fields, clockwise.

5. Assesses EOMs by examining:
a. for parallel alignment.

b. the corneal light reflex.
c. the ability to move through the six cardinal gaze positions.

d. the cover/uncover test.

6. Inspects external structures:

a. Color and alignment of eyes.

b. Eyelids: notes any lesions, edema, or lid lag.

c. Symmetry and distribution of eyelashes.

d. Lacrimal ducts and glands, checks for edema, and drainage.

e. Notes color, moisture, and contour of conjunctiva.

f. Inspects both palpebral and bulbar conjunctiva.

g. Sclera: Notes color and presence of lesions.

h. Inspects cornea and lens with penlight; notes color and lesions.

i. Tests the corneal reflex with a cotton wisp.

j. Notes color, size, shape, and symmetry of iris and pupils.

k. Checks pupil reaction for direct and consensual response.

l. Assesses pupil accommodation by having the patient focus on an approaching object.

m. Inspects anterior chamber with penlight, for color, size, shape, and symmetry.

7. Palpates the external eye structures for tenderness and discharge; palpates globes and lacrimal glands and ducts.

8. Assesses the internal structures via ophthalmoscopy.

Darkens the room.

a. Stands about 1 foot from the patient at a 15 degree lateral angle.

b. Dials the lens wheel to zero with index finger.

c. Holds ophthalmoscope to own brow.

d. Has the patient look straight ahead while shining the light on one pupil to identify the red light reflex.

e. Once the red light reflex is identified, moves in closer to within a few inches of the eye and observes the internal structures of the eye. Adjusts the lens wheel to focus as needed.

f. Uses right eye to examine the patient’s right eye, and left eye to examine the patient’s left eye.

Recommendation: Pass _____ Needs more practice _____

Student: Date:

Instructor: Date:

PROCEDURE CHECKLIST

Assessing the Female Genitourinary System

Check (ü) Yes or No

PROCEDURE STEPS

Yes

COMMENTS

1. Instructs client to disrobe to expose the pelvic area.

2. Positions patient in lithotomy or Sims position, providing support as needed.

3. Inspects external genitalia.

a. Notes distribution and condition of pubic hair.

b. Inspects mons, pubis, and labia for color, lesions, and discharge.

4. Wearing gloves, uses thumb and index finger to separate the labia and expose the clitoris; observes for size and position.

5. With labia separated, observes urethral meatus and vaginal introitus for color, size, and presence of discharge or lesions. Then asks client to bear down while observing the introitus for bulging or discomfort.

6. Palpates Bartholin’s and Skene’s glands.

a. Lubricates gloved middle and index fingers of dominant hand with water soluble lubricant.

b. Palpates Bartholin’s gland by inserting fingers into the introitus and palpating the lower portion of the labia bilaterally between thumb and fingers.

c. Palpates Skene’s glands by then rotating the internal fingers upward and palpating the labia bilaterally.

d. Milks the urethra by applying pressure with index finger on the anterior vaginal wall; cultures any discharge.

7. Assesses vaginal and pelvic muscle tone by inserting 2 gloved fingers into the vagina and asking the woman to constrict her vaginal muscles, and then to bear down as if she is having a bowel movement.

8. Palpates lymph nodes in the groin area and the vertical chain over the inner aspect of the thigh.

Recommendation: Pass _____Needs more practice _____

Student: Date:

Instructor: Date:

PROCEDURE CHECKLIST

Assessing the Hair

Check (ü) Yes or No

PROCEDURE STEPS

Yes

COMMENTS

1. Assesses both scalp hair and body hair.

· 2. Inspects and palpates scalp; notes mobility, tenderness, and lesions.

3. Assesses hair color, quantity, and distribution; condition of scalp; and presence of lesions or pediculosis.

4. Palpates hair texture.

Recommendation: Pass _____ Needs more practice _____

Student: Date:

Instructor: Date:

PROCEDURE CHECKLIST

Assessing the Head and Face

Check (ü) Yes or No

PROCEDURE STEPS

Yes

COMMENTS

1. Compares side to side throughout the exam.

2. Inspects head for size, shape, symmetry, and position.

3. Inspects face for expression and symmetry.

4.Palpates head for masses, tenderness, and scalp mobility.

5.Palpates face for symmetry, tenderness, muscle tone and TMJ function.

Recommendation: Pass _____ Needs more practice _____

Student: Date:

Instructor: Date:

PROCEDURE CHECKLIST

Assessing the Heart and Vascular System

Check (ü) Yes or No

PROCEDURE STEPS

Yes

COMMENTS

· 1. Inspects the neck and chest.

· a. Positions patient supine.

b. Observes carotid arteries.

2. Assesses jugular flow by compressing jugular vein below the jaw and observing jugular wave.

3. Assesses jugular filling by compressing jugular vein above the clavicle and observing for disappearance of jugular wave.

· 4. Measures jugular venous pressure (JVP).

a. Elevates the head of the bed to a 45º angle.

b. Identifies the highest point of visible internal jugular filling.

c. Places a ruler vertically at the sternal angle (where the clavicles meet).

d. Places another ruler horizontally at the highest point of the venous wave.

e. Measures the distance in centimeters vertically from the chest wall.

5. Places patient supine with tangential lighting to inspect precordium for pulsations.

6. Palpates the carotid arteries.

a. Palpates each side separately.

b. Avoids massaging the artery.

c. Notes rate, rhythm, amplitude, and symmetry of pulse.

d. Notes contour, symmetry, and elasticity of the arteries; notes any thrills.

7. Palpates the precordium.

a. Has patient sit up and lean forward; if lying down, turns patient to the left side.

b. Palpates: apex, left lateral sternal border, epigastric area, base left, and base right.

8. Works from patient’s right side to auscultate, if possible.

9. Auscultates the carotids: uses bell of stethoscope, has patient hold his breath while listening.

10. Auscultates jugular veins: uses bell of stethoscope, has patient hold his breath while listening.

11. Auscultates the precordium:

a. Identifies S1, S2, S3, and S4 sounds.

b. Listens for murmurs.

c. Listens with both bell and diaphragm at all four locations.

d. Listens at: base right (aortic valve), base left (pulmonic valve), apex (mitral valve), and left lateral sternal border (tricuspid valve).

12. If murmur is heard, identifies variables affecting (e.g., location, quality, pitch, intensity, timing, duration, configuration, radiation, and respiratory variation) and compares with previous findings. Refers to primary care if murmur is a new finding.

13. Inspects the periphery for color, temperature, and edema.

14. Palpates the peripheral pulses: radial, brachial, femoral, popliteal, dorsalis pedis, and posterior tibial.

a. Uses distal pads of 2^nd and 3^rd fingers to firmly palpate pulses.

b. Palpates firmly but does not occlude artery.

c. Assesses pulses for rate, rhythm, equality, amplitude, and elasticity.

d. Describes pulse amplitude on a scale of 0 to 4:

0 = absent, not palpable

1 = diminished, barely palpable

2 = normal, expected

3 = full, increased

4 = bounding

15. Inspects the venous system. If a client has varicosities, assess for valve competence with the manual compression test.

Recommendation: Pass _____ Needs more practice _____

Student: Date:

Instructor: Date:

PROCEDURE CHECKLIST

Assessing the Male Genitourinary System

Check (ü) Yes or No

PROCEDURE STEPS

Yes

COMMENTS

1. Instructs client to empty his bladder and undress to expose the groin area.

· 2. Positions patient standing and sits at eye level to the genitalia; or positions patient supine with legs slightly apart.

3. Inspects external genitalia.

a. Notes distribution and condition of pubic hair.

· b. Inspects penis, noting condition of skin, presence or absence of foreskin, position of urethral meatus, and any lesions or discharge.

c. Observes the scrotum for: skin condition, size, position, and symmetry.

d. Inspects inguinal areas for swelling or bulges.

4. Palpates penis.

a. Uses thumb and fingers of gloved hand.

b. Notes consistency, tenderness, masses, or nodules.

c. Retracts foreskin if present.

5. Palpates scrotum, testes, and epididymis.

a. Uses thumb and fingers of gloved hand. Notes size, shape, consistency, mobility, masses, nodules, or tenderness.

b. Transilluminates any lumps, nodules, or edematous areas by shinning a pen light over the area in a darkened room.

6. Palpates for inguinal hernias with a gloved hand. Has the patient hold his penis to one side. Places index finger in the client’s scrotal sac above the testicle and invaginates the skin. Follows the spermatic cord until reaching a slitlike opening (Hesselbach’s triangle). Asks the client to cough or bear down while feeling for bulges.

7. Palpates for femoral hernias by palpating below the femoral artery while having the client cough or bear down.

8. Palpates the lymph nodes in the groin area and the vertical chain over the inner aspect of the thigh.

Recommendation: Pass _____ Needs more practice _____

Student: Date:

Instructor: Date:

PROCEDURE CHECKLIST

Assessing the Mouth and Oropharynx

Check (ü) Yes or No

PROCEDURE STEPS

Yes

COMMENTS

1. Inspects mouth externally. Notes the placement, color, and condition of lips. Asks client to purse the lips.

2. Notes color and condition of oral mucosa and gums:

a. Inspects inside lower lip.

b. Uses tongue depressor and penlight to inspect buccal mucosa, and Stensen’s ducts.

c. Palpates inside each cheek.

d. Inspects gums for color, bleeding, edema, retraction, and lesions.

e. Palpates gums for firmness.

3. Inspects teeth for color, condition, and occlusion.

4. If client wears dentures, asks her to remove them; inspects for condition and fit.

5. Inspects tongue and floor of the mouth.

a. Asks client to stick out his tongue. Examines upper surface for color, texture, position, and mobility.

b. Has client place tip of tongue on roof of his mouth; uses penlight to inspect underside of tongue, frenulum, floor of mouth, and submaxillary glands.

c. Using tongue blade or gloved finger, moves tongue aside and examines lateral aspects of tongue and floor of mouth.

d. Palpates tongue and floor or mouth, stabilizing the tongue by grasping with a gauze pad.

6. Inspects the oropharynx (hard/soft palate, tonsils and uvula); notes color, shape, texture, and condition.

a. Has the client tilt his head back and open his mouth as widely as possible. Depresses the tongue with a tongue blade and shines a penlight on the areas to be inspected.

b. To inspect the uvula, asks the client to say “ah” and watches the uvula as the soft palate rises.

c. Inspects the oropharynx by depressing one side of the tongue at a time, about halfway back on the tongue.

d. Notes the size and color of the tonsils; notes any discharge.

7. Tests the gag reflex by touching the back of the soft palate with a tongue blade.

Recommendation: Pass _____ Needs more practice _____

Student: Date:

Instructor: Date:

PROCEDURE CHECKLIST

Assessing the Musculoskeletal System

Check (ü) Yes or No

PROCEDURE STEPS

Yes

COMMENTS

1. Compares bilaterally during assessment.

2. Assesses posture, body alignment, and symmetry.

3. Assesses spinal curvature:
a. Standing erect.
b. Bending forward at waist, arms hanging free at sides.

4. Examines gait by observing client walking; notes:

a. Base of support (distance between the feet).

b. Stride length (distance between each step.

c. Phases of the gait.

5. Assesses balance through:

a. Tandem walking.

b. Heel and toe walking.

c. Deep knee bends.

d. Hopping.

e. Romberg test (feet together, eyes open; then eyes closed).

6. Assesses coordination:

a. Assesses with client seated.

b. Tests finger-thumb opposition.

c. Tests rapid alternating movements by having client alternate supination and pronation of the hands.

d. Tests rhythmic toe-tapping, one side at a time.

e. Has client run heel of one foot down the shin of the other leg; repeats on opposite side.

7. Tests the accuracy of movements by having the client touch his finger to his nose with his eyes closed.

8. Measures arm length from acromion process to the tip of the middle finger.

9. Measures leg length from the anterior superior iliac crest to the medial malleolus.

10. Measures circumference of forearms, upper arms, thighs, and calves.

11. Inspects symmetry and shape of muscles and joints.

12. Notes surgical scars indicating joint surgeries.

13. Tests active ROM by asking client to move each of the following joints: temporomandibular, neck, thoracic and lumbar spine; shoulder, upper arm and elbow; wrist, hands, and fingers; hip, knee, ankles, and feet.

14. Checks for the following joint movements:

a. Temporo-
mandibular

Able to flex, extend, move side-to-side, protrude, and retract the jaw.

b. Neck

Flexes, extends, hyperextends, bends laterally, and rotates side-to-side.

c. Thoracic and lumbar spine

Able to bend at the waist, stand upright, hyperextend (bend backward), bend laterally, and rotate side-to-side.

d. Shoulder

Able to move the arm forward and backward, abduct, adduct, and rotate internally and externally.

e. Upper arm and elbow

Able to bend, extend, supinate, and pronate the elbow.

f. Wrist

Flexes, extends, hyperextends, and moves side-to-side.

g. Hands and fingers

Able to spread the fingers (abduct), bring them together (adduct), make a fist (flex), extend the hand (extend), bend fingers back (hyperextend), and bring thumb to index finger (palmar adduction).

h. Hip

Able to extend the leg straight, flex the knee to the chest, abduct and adduct the leg, rotate the hip internally and externally, and hyperextend the leg.

i. Knee

Able to flex and extend the knee.

j. Ankles and feet

Able to dorsiflex, plantar flex, evert, invert, abduct, and adduct the feet and ankles.

15. Assesses muscle strength by having the client perform ROM against resistance.

16. Rates muscle strength correctly using the following rating scale:

Rating

Criteria

Classification

Active motion against full resistance

Normal

Active motion against some resistance

Slight weakness

Active motion against gravity

Weakness

Passive ROM

Poor ROM

Slight flicker of contraction

Severe weakness

No muscular contraction

Paralysis

Recommendation: Pass _____ Needs more practice _____

Student: Date:

Instructor: Date:

PROCEDURE CHECKLIST

Assessing the Nails

Check (ü) Yes or No

PROCEDURE STEPS

Yes

COMMENTS

1. Compares bilaterally throughout exam.

2. Inspects nails for color, condition, and shape.

3. Palpates the texture of the nails.

4. Correctly assesses capillary refill by pressing on the nails and releasing.

5. Examines nails on both hands and feet; or states he will defer examination of the toenails until the assessment of peripheral circulation.

Recommendation: Pass _____Needs more practice _____

Student: Date:

Instructor: Date:

PROCEDURE CHECKLIST

Assessing the Neck

Check (ü) Yes or No

PROCEDURE STEPS

Yes

COMMENTS

1. Inspects the neck in neutral and hyperextended position, and while patient swallows water.

2. Notes symmetry, range of motion (ROM), and condition of skin.

3. Palpates the cervical lymph nodes.

a. Uses light palpation with one or two fingerpads, in a circular movement.

b. Palpates all nodes: pre-auricular, posterior auricular, tonsillar, submandibular, submental, occipital, superficial cervical, deep cervical, posterior cervical, and supraclavicular.

c. Notes the size, shape, symmetry, consistency, mobility, tenderness, and temperature of any palpable nodes.

4. Palpates the thyroid, using correct technique.

To use the posterior approach:

a. Stands behind the client and asks him to flex his neck slightly forward and to the left.

b. Positions thumbs on the nape of the client’s neck.

c. Using the fingers of the left hand, locates the cricoid cartilage. Pushes the trachea slightly to the left with the right hand while palpating just below the cricoid and between the trachea and sternocleidomastoid muscle. Asks client to swallow (gives small sips of water if necessary) and feels for the thyroid gland as it rises up.

d. Reverses and repeats the same steps to palpate the right thyroid lobe (uses fingers of left hand to displace the trachea to the right while using the fingers of the right hand to palpate the thyroid to the right of the trachea).

To use the anterior approach:

e. Stands in front of the client and asks him to flex his neck slightly forward and in the direction the nurse intends to palpate.

f. Places hands on the neck and applies gentle pressure to one side of the trachea while palpating the opposite side of the neck for the thyroid as the client swallows.

g. Reverses and repeats the same steps on the opposite side.

5. If thyroid is enlarged, or there is a mass, follows up with auscultation of the gland.

Recommendation: Pass _____ Needs more practice _____

Student: Date:

Instructor: Date:

PROCEDURE CHECKLIST

Assessing the Nose and Sinuses

Check (ü) Yes or No

PROCEDURE STEPS

Yes

COMMENTS

1. Compares right and left sides throughout examination.

2. Inspects the external nose.

a. Notes the position, shape, and size; discharge and flaring.

3. Checks for patency of the nasal passages.
a. Asks the client to close his mouth, hold one naris closed, and breathe through the other naris. Repeats with opposite naris.

4. Inspects the internal structures.

a. Holds speculum in right hand to inspect left nostril; in left hand to inspect right nostril.

b. Tilts the client’s head back to facilitate speculum insertion and visualization.

c. Braces index finger against the client’s nose as inserting the speculum..

d. Inserts the speculum about 1 cm into the naris; opens as much as possible.

e. Uses the other hand to position client’s head and hold penlight.

f. Observes the nasal mucosa for color, edema, lesions, and discharge.

g. Inspects the septum for position and intactness.

h. Infants and children—Does not use a speculum to examine internal structures. Pushes the tip of the nose upward with thumb and directs a penlight into the nares.

5. Transilluminates the frontal and maxillary sinuses.

a. Darkens the room.

b. Frontal sinuses: Shines a penlight or the otoscope with speculum below eyebrow on each side.

c. Maxillary sinuses: Places the light source below the eyes and above the cheeks. Looks for a glow of red light at the roof of the mouth through the client’s open mouth.

6. Palpates the external structures.

7. Palpates the frontal and maxillary sinuses.

Recommendation: Pass _____ Needs more practice _____

Student: Date:

Instructor: Date:

PROCEDURE CHECKLIST

Assessing the Sensory-Neurological System

Check (ü) Yes or No

PROCEDURE STEPS

Yes

COMMENTS

1. Assesses behavior, noting facial expression, posture, affect, and grooming.

· 2. Determines level of arousal using, as needed, and in this order: verbal stimuli, tactile stimuli, painful stimuli.

· 3. Correctly describes altered levels of arousal using the Glasgow Coma Scale.

· 4. Determines level of orientation.

a. Checks orientation to time.

b. Checks orientation to place.

c. Checks orientation to person.

· 5. Assesses immediate, recent, and remote memory.

· Uses correct method to assess each type of memory:

· a. Immediate memory (asks client to repeat a series of numbers, beginning with a series of three). Then repeats test, asking client to repeat numbers in reverse order.

· b. Recent memory (names 3 items and asks client to recall them later in the exam; or asks “How did you get to the hospital?” and so forth).

· c. Remote memory (asks birth date, for example).

· 6. Assesses mathematical and calculative skills, beginning with simplest problem and progressing to more difficult.

a. Considers the person’s language, education, and culture in deciding whether this test is appropriate for him.

b. Uses the following tests, as appropriate:
1) Has the client solve a simple mathematical problem, such as 3 +3.
2) If client is able to solve that problem, presents a more complex example, such as: If you have $3.00 and you buy an item for $2.00, how much money will you have left?
3) To assess both calculation skills and attention span, asks the client to count backward from 100.

4. A more difficult test is to have the client perform serial threes or serial sevens. Asks him to begin at 100 and keep subtracting 3 (or 7).

· 7. Assesses general knowledge by asking the client how many days in the week or months in the year.

· 8. Evaluates thought processes throughout the exam. Assesses attention span, logic of speech, ability to stay focused, and appropriateness of responses.

· 9. Assesses abstract thinking, for example, by asking the client to interpret a proverb, such as “A penny saved is a penny earned.”

· 10. Assesses judgment by asking the client to respond to a hypothetical situation, such as “If you were walking down the street and saw smoke and flame coming from a house, what would you do?”

· 11. Assesses communication ability.

a. During the exam, notes the rate, flow, choice of vocabulary, and enunciation in client’s speech.

b. Tests spontaneous speech: Shows client a picture and has him describe it.

c. Tests motor speech by having the client say “do, re, mi, fa, so, la, ti, do.”

d. Tests automatic speech by having the client recite the days of the week.

e. Tests sound recognition by having the client identify a familiar sound, such as clapping hands.

f. Tests auditory-verbal comprehension by asking the client to follow simple directions (e.g., point to your nose, rub your left elbow).

g. Tests visual recognition by pointing to objects and asking the client to identify them.

h. Tests visual-verbal comprehension by having the client read a sentence and explain its meaning.

i. Tests writing by having the client write his name and address.

j. Tests copying figures by having the client copy a circle, x, square, triangle and star.

· 12. CN I–checks patency of nostrils, checks one nostril at a time for client’s ability to identify the smell of common substances.

· 13. CN II–tests visual acuity and visual fields; performs fundoscopic exam.

· 14. CN III, IV, and VI–

a. Tests EOMs by having the client move the eyes through the 6 cardinal fields of gaze with the head held steady.

b. Tests pupillary reaction to light and accommodation.

· 15. CN V, motor function–has client move his jaw from side to side, clenching his jaw, and biting down on a tongue blade.

· 16. CN V, sensory function–has the client close his eyes and identify when nurse is touching his face at the forehead, cheeks, and chin bilaterally—first with the finger and then with a toothpick.

· 17. Tests corneal reflex by touching the cornea with a wisp of cotton or puffing air from a syringe over the cornea.

· 18. CN VII, motor function–has the client make faces, such as smile, frown or whistle.

· 19. CN VII, taste–tests taste on the anterior portion of the tongue by placing sweet (sugar), salty (salt), or sour (lemon) substance on tip of tongue.

· 20. CN VIII–Uses:

a. Watch-tick test for hearing.

b. Weber and Rinne tests for air and bone conduction.

c. Romberg test for balance (if not already done).

· 21. CN IX and X–observes ability to talk, swallow, and cough.

· 22. CN IX and X, motor function–asks client to say “ah” while depressing tongue with a tongue blade and observing the soft palate and uvula to rise.

· 23. CN IX and X, sensory function–touches back of pharynx with tongue blade to induce a gag reflex.

· 24. CN IX and X, taste (sweet, salty, sour)–tests on posterior portion of tongue.

· 25. CN XI (if not assessed with musculoskeletal exam):

· a. Places hands on client’s shoulders and has client shrug his shoulders against resistance.

· b. Has client turn his head from side to side against resistance.

· 26. CN XII–has the client:

· a. Say “d, l, n, t.”

· b. Protrude the tongue and move it from side to side.

· 27. When testing superficial sensations:

· a. Begins with the most peripheral part of the limb.

· b. If client does not perceive the touch, determines boundaries by testing at about every inch (2.5 cm); sketches the area of sensory loss.

· c. Waits 2 seconds before moving to a new site.

· d. Tests first with wisp of cotton, then tests for pain with toothpick or sterile needle (first the dull, then the sharp end).

· e. Alternates dull and sharp ends when moving from spot to spot.

· f. Tests temperature sensation if pain perception is abnormal.

· 28. Tests deep vibratory sensation by placing a vibrating tuning fork on a metatarsal joint and distal interphalangeal joint and having the patient identify when the vibration is felt and when it stops.

· 29. Tests deep kinesthetic sensation (position sense) by holding the client’s finger or toe on the sides and moving it up or down. Instructs client to keep his eyes closed and identify the direction of the movement.

· 30. Performs all discriminatory sensation tests: stereognosis, graphesthesia, 2-point discrimination, point localization, and sensory extinction.

· 31. Uses correct procedure to test discriminatory sensation tests:

a. Assesses stereognosis by placing a familiar object (e.g., a coin or a button) in the palm of the client’s hand and having him identify it.

b. Assesses graphesthesia by drawing a number or letter in the palm of patient’s hand and having the patient identify what was drawn.

c. Tests 2-point discrimination with toothpicks. Has the patient close his eyes. Touches him on the finger with 2 separate toothpicks simultaneously. Gradually moves the points together and has the patient say “one” or “two” each time the toothpicks are moved. Documents distance and location at which he can no longer feel 2 separate points.

d. Tests point localization by having the patient close his eyes while the nurse touches him. Have him point to the area touched. Repeat on both sides and upper and lower extremities.

e. Tests sensory extinction by simultaneously touching the patient on both sides (e.g., on both hands, both knees, both arms). Has the patient identify where he was touched.

· 32. Tests each of the following deep tendon reflexes: biceps, triceps, brachioradialis, patellar, and Achilles.

· 33. Uses correct procedure to test each reflex:

a. Biceps reflex (spinal cord level C–5 and C–6). Rests the patient’s elbow in nondominant hand, with thumb over the biceps tendon. Strikes the percussion hammer to own thumb.

b. Triceps reflex (spinal cord level C–7 and C–8). Abducts patient’s arm at the shoulder and flexes it at the elbow. Supports the upper arm with nondominant hand, letting the forearm hang loosely. Strikes the triceps tendon about 1–2 inches (2.5 to 5 cm) above the olecranon process.

c. Brachioradialis reflex (spinal cord level C–3 and C–6). Rests patient’s arm on patient’s leg. Strikes with the percussion hammer 1–2 inches (2.5 to 5 cm) above the bony prominence of the wrist on the thumb side.

d. Patellar reflex (spinal cord level L–2, L–3, and L–4). Has patient sit with legs dangling. Strikes the tendon directly below the patella.

e. Achilles reflex (spinal cord level S–1, S–2). Has the patient lie supine or sit with the legs dangling. Holds the patient’s foot slightly dorsiflexed and strikes the Achilles tendon about 2 inches (5 cm) above the heel with the percussion hammer.

· 34. Uses the following scale to grade reflexes:

0 No response detected

+1 Diminished response

+2 Response normal

+3 Response somewhat stronger than normal

+4 Response hyperactive with clonus

· 35. Tests plantar superficial reflex with thumbnail or pointed object. Strokes sole of foot in an arc from the lateral heel to medially across the ball of the foot.

Recommendation: Pass _____ Needs more practice _____

Student: Date:

Instructor: Date:

PROCEDURE CHECKLIST

Assessing the Skin

Check (ü) Yes or No

PROCEDURE STEPS

Yes

COMMENTS

1. Uses inspection, palpation, and olfaction.

2. Assesses both exposed and unexposed areas.

3. Compares side to side throughout exam.

4. Inspects skin color.

5. Notes unusual odors.

6. Inspects and palpates lesions.

7. For identified lesions, describes size, shape, color, distribution, texture, surface relationship, exudates, tenderness, or pain.

8. Uses ABCDE method to evaluate lesions that may need referral due to potential malignancy.

9. Palpates skin temperature with dorsal aspect of hand or fingers.

10. Palpates skin turgor by gently pulling up skin and noting its return.

11. Palpates skin texture, moisture, and hydration.

12. Inspects for edema. Notes location, degree, and type if present.

13. Considers culture/ethnicity, gender, and developmental stage of client in interpreting data.

Recommendation: Pass _____ Needs more practice _____

Student: Date:

Instructor: Date:

PROCEDURE CHECKLIST

Measuring Blood Pressure

Check (ü) Yes or No

PROCEDURE STEPS

Yes

COMMENTS

1. If possible, positions patient sitting, feet on floor, legs uncrossed; alternatively, lying down.

2. Measures BP after patient has been inactive for 5 min.

3. Exposes arm (does not auscultate through clothing).

4. Supports patient’s arm at the level of the heart.

5. Uses appropriately sized cuff. (The width of the bladder of a properly fitting cuff will cover approximately 2/3 of the length of the upper arm for an adult, and the entire upper arm for a child. Alternatively, the length of the bladder encircles 80% to 100% of the arm in adults.)

6. Positions cuff correctly; wraps snugly.

7. Palpates radial artery, closes sphygmomanometer valve, and inflates cuff to determine mm Hg at which radial artery can no longer be felt.

8. Places stethoscope on brachial artery and continues to inflate cuff rapidly to 30 mm Hg above level previously determined by palpation.

9. Ensures that stethoscope tubing is not touching anything.

10. Releases pressure at 2–3 mm Hg/second.

11. Reads mercury manometer at eye level

12. Records at least systolic/diastolic (first and last sounds heard—e.g., 110/80). Records level of muffling, if possible.

13. If necessary to remeasure, waits at least 2 minutes.

Recommendation: Pass _____ Needs more practice _____

Student: Date:

Instructor: Date:

PROCEDURECHECKLIST

Performing the General Survey

Check (ü) Yes or No

PROCEDURE STEPS

Yes

COMMENTS

1. Observes for signs of distress; alters approach if patient is distressed.

2. Observes apparent age, gender, and race.

3. Notes facial characteristics, symmetry of features, expression, and condition and color of skin.

4. Notes body type and posture.

5. Greets patient with handshake to assess muscle strength

(if culturally appropriate).

6. Observes gait and any abnormal movements (or ability to move about in bed).

7. Listens to speech pattern, pace, quality, tone, vocabulary, and sentence structure.

8. Obtains interpreter if there is a language barrier.

9. Assesses general mental state and affect.

10. Observes dress, grooming, and hygiene.

11. Measures vital signs.

12. Measures height and weight.

a. Adults: Calculates BMI from height and weight measurement.

b. Infants and children < 2 years: Height—positions supine with knees extended; also measures head circumference.

c. Infants: Weighs without clothing;

d. Older children: Weighs in underwear.

13. For children, plots height and weight on growth chart and evaluates trends.

Recommendation: Pass _____ Needs more practice _____

Student: Date:

Instructor: Date:

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