physicalassessmentcheckoff

MISSISSIPPI UNIVERSITY FOR WOMEN
RN/BSN OPTION: TUPELO CAMPUS
NU 359
EVALUATION OF PHYSICAL EXAM

GENERAL INFORMATION

1. Bring your check-off sheet and completed client assessment tool and ROS (Review of Systems)
2. You are responsible for the following equipment/supplies:

a. Stethoscope
b. Penlight
c. Taste and smell items (2of each)
d. Reflex hammer
e. Towel
f. Button, coin, paper clip, cotton swabs/balls, tongue blades, etc.
g. Gloves
h. Index Card
i. Pen
j. tape measure
k. drinking cup

3. There will be a ophthalmoscope/otoscope, BP cuff and tuning fork in class room.

PRE-EXAM

1. Assemble equipment necessary for exam (Snellen chart / news print, BPcuff ophthalmoscope, otoscope, nose/ear speculums, tuning fork, tongue blade, penlight, glove, stethoscope, eye cover (card), cup of water, etc.)
2. Introduce self and explain procedure/confidentiality. Obtain health history (to be done prior to exam).
3. Have client dress for exam.

EXAMINATION

1. Develop a personal routine, perform examination procedures systematically and efficiently using a system that requires the fewest number of client position changes, and prevents the examiner moving back and forth between body systems during the exam.
2. Ask pertinent questions related to personal and family medical history.
3. Explain each part of examination to client as it is performed.
4. Demonstrate consideration for client's privacy.
5. Observe general appearance: grooming, emotional status, body language,speech pattern, motor ability, etc.

POST-EXAMINATION
Document findings on Client Assessment Tool and Review of Systems/Physical Exam Forms. Submit these forms in 1 week to faculty

A one hour time limit will be granted per check-off. All areas must be satisfactory. The student will have three (3) opportunities to successfully complete assessment criteria. If unsuccessful after three attempts, the clinical portion of the course will be considered unsatisfactory and this will constitute a course failure.

PHYSICAL ASSESSMENT CHECK OFF

OBJECTIVE: To illustrate the incorporation of the separate body system examination into one complete integrated physical examination.

I. Evaluation of Physical Assessment S- U- Comments---

A. Introduction --- --- ----------------

1. Explain exam to client - - -

2. Explain clients right to refuse and confidentiality - - -

B. Balance/Motor Coordination --- - -

1. Romberg - - -

2. Heal to toe walking (tandem walking) - - -

3. Single foot balance - - -

4. Hopping in place - - -

5. Knee bends - - -

C. Back - - -

1. Inspect back - - -

2. Check for scoliosis - - -

3. Palpate spine - - -

4. Palpate back muscles - - -

5. Bend side to side and twist - - -

D. Integumentary (Upper) ----- ----- ------------------------

1.Skin, nails - - -

E. Extremities (Upper) (Sitting) - - -

1. Inspection - - -

2. Pulses (Ulnar, Radial, Brachial) - - -

3. Sensory (light/deep, sharp/dull) - - -

4. ROM of joints - - -

5. Palpation of all joints (Hands, Arms, Shoulder, TMJ) - - -

6. Stereognosis (times 2 bilaterally) - - -

7. Graphesthesia - - -

8. Vibration (times 2 bilaterally) - - -

9. Two point discrimination - - -

10. Reflexes
a. Biceps
b. Triceps
c. Brachial - - -

11. Motor/coordination(Specify heal to shin, finger to thumb/touch nose) - - -

F. Head - - -

1. Inspect vision placement (Far/near) and symmetry - - -

2. Inspect scalp - - -

3. Palpate scalp - - -

G. Eyes - - -

1. Inspect placement and symmetry - - -

2. Inspect conjunctiva - - -

3. Puncta - - -

4. Inspect sclera & cornea & iris - - -

5. Alignment (cover/uncover) - - -

6. E.O.M. - - -

7. Accommodation - - -

8. Direct light reaction - - -

9. Consenual light reaction - - -

10. Visual fields - - -

11. Corneal reflex - - -

12. Fundoscopic - 1. Position, 2. Approach 3. Anterior chamber - - -

13. Vision (far/near) - - -

H. Cranial Nerves not covered previously - - -

1. Trigeminal - Sensory of forehead, face,jaw (Closing of jaw) - - -

2. Facial - raise eyebrows, wrinkle forehead, show teeth, smile, puff cheeks, - - -

3. Accessory - shrugging shoulders head to shoulder, resist head to hands - - -

I. Ears - - -

1. Inspect outer ear, symmetry - - -

2. Inspect/palpate pinna - - -

3. Gross hearing, whisper test - - -

4. Weber, Rinne - - -

5. Otoscopic Exam: Describe land marks.(Cone of light, malleus, umbo) - - -

J. Nose - - -

1. Inspect: mucosa, septum deviation, symmetry, turbinates - - -

2. Assess patency of nose - - -

3. Palpate (external nose, sinuses, frontal & maxillary) - - -

4. Test sense of smell - - -

K. Mouth and Pharynx - - -

1. Inspect mouth: Mucosa, gums and teeth - - -

2. Inspect Tongue (sublingual also) - - -

3. Tongue: motor/deviation - - -

4. Inspect pharynx, Uvula/palate movement on phonation. - - -

5. Sense of Taste - - -

L. Neck --- --- ------------

1. Inspect neck (inc. R.O.M/strength) - - -

2. Palpate trachea position - - -

3. Palpate thyroid - - -

4. Auscultate carotid - - -

M. Lymph Nodes - - -

1. Occipital - - -

2. Post auricular / pre-auricular - - -

3. Tonsillar - - -

4. Submaxillary/Submandibular - - -

5. Submental - - -

6. Ant./Posterior cervical chains - - -

7. Supraclavicular/Infraclavicular - - -

8. Axillary - - -

N. Posterior Thorax and Lungs (Sitting) - - -

1. Inspect (contour, pattern, etc.) - - -

2. Respiratory pattern - - -

3. Palpate for respiratory expansion - - -

4. Palpate fremitus-compare sides - - -

5. Percuss lung fields - - -

6. Percuss for diaphragmatic excursion - - -

7. Auscultate lung fields - - -

8. Costalvertebral rebound - - -

O. Anterior, Thorax and Lungs (Sitting) - - -

1. Inspect - - -

2. Palpate for fremitus - - -

3. Percuss lung fields - - -

4. Auscultate lungs - - -

P. Heart (Sitting) ---- ---- ----------------

1. Palpate for lifts, heaves or thrills, PMI - - -

2. Auscultate (Bell/Diaphragm) - - -

a. aortic (murmur) - - -

b. pulmonic - - -

c. Erb's point - - -

d. tricuspid - - -

e. mitral (count heartbeat) - - -

Q. Heart (Supine) - - -

1. (Observe JVD)Inspect for heaves/pulsations/thrills - - -

2. Auscultate (Bell/Diaphragm) - - -

a. aorta - - -

b.pulmonic - - -

c. Erb's point - - -

d. tricuspid - - -

e. mitral (murmur) - - -

R. Abdomen - - -

1. Inspect - - -

2. Auscultate all four quadrants for Bowel sounds - - -

3. Auscultate arteries (Aorta, Renal, Femoral) - - -

4. Percuss: all four quadrants - - -

5. Percuss spleen - - -

6. Percuss liver - - -

5. Palpate all four quadrants (Light/deep) - - -

6. Palpate Liver - - -

7 Palpate Spleen - - -

8. Palpate Kidneys - - -

9. Palpate Aorta - - -

10. Palpate Femoral Pulse - - -

11. Abdominal Reflex - - -

S. Extremities (lower supine) ------ ----- -----------------------

1. Inspection/general - - -

2. Palpate Pulses - - -

a Popliteal - - -

b. Dorsalis Pedis - - -

c. Postereior Tibial - - -

3. Sensory (light/deep, sharp/dull) - - -

4. ROM of joints, position sense - - -

5. Palpation of all joints - - -

6. Strength - - -

7. Reflexes - - -

a. Achilles - - -

b. Babinski - - -

c. Patella - - -

d. Homan's sign - - -

e. Clonus - - -

II. Organization (For more detailed explanation, Use Recommendations) - - -

A. Uses correct vocabulary - - -

B. Maintains privacy - - -

C. Uses appropriate sequence - - -

D. Examines thoroughly - - -

E. Uses organized approach - - -

III. Recommendations

STUDENT_____________________________
SS #_________________________________
FACULTY_______________________
GRADE______________________________

Revised: Spring 2001
Revised Summer 2002

A. Introduction	---	---	----------------
1. Explain exam to client	-	-	-
2. Explain clients right to refuse and confidentiality	-	-	-
B. Balance/Motor Coordination	---	-	-
1. Romberg	-	-	-
2. Heal to toe walking (tandem walking)	-	-	-
3. Single foot balance	-	-	-
4. Hopping in place	-	-	-
5. Knee bends	-	-	-
C. Back	-	-	-
1. Inspect back	-	-	-
2. Check for scoliosis	-	-	-
3. Palpate spine	-	-	-
4. Palpate back muscles	-	-	-
5. Bend side to side and twist	-	-	-

D. Integumentary (Upper)	-----	-----	------------------------
1.Skin, nails	-	-	-
E. Extremities (Upper) (Sitting)	-	-	-
1. Inspection	-	-	-
2. Pulses (Ulnar, Radial, Brachial)	-	-	-
3. Sensory (light/deep, sharp/dull)	-	-	-
4. ROM of joints	-	-	-
5. Palpation of all joints (Hands, Arms, Shoulder, TMJ)	-	-	-
6. Stereognosis (times 2 bilaterally)	-	-	-
7. Graphesthesia	-	-	-
8. Vibration (times 2 bilaterally)	-	-	-
9. Two point discrimination	-	-	-
10. Reflexes a. Biceps b. Triceps c. Brachial	-	-	-
11. Motor/coordination(Specify heal to shin, finger to thumb/touch nose)	-	-	-
F. Head	-	-	-
1. Inspect vision placement (Far/near) and symmetry	-	-	-
2. Inspect scalp	-	-	-
3. Palpate scalp	-	-	-
G. Eyes	-	-	-
1. Inspect placement and symmetry	-	-	-
2. Inspect conjunctiva	-	-	-
3. Puncta	-	-	-
4. Inspect sclera & cornea & iris	-	-	-
5. Alignment (cover/uncover)	-	-	-
6. E.O.M.	-	-	-
7. Accommodation	-	-	-
8. Direct light reaction	-	-	-
9. Consenual light reaction	-	-	-
10. Visual fields	-	-	-
11. Corneal reflex	-	-	-
12. Fundoscopic - 1. Position, 2. Approach 3. Anterior chamber	-	-	-
13. Vision (far/near)	-	-	-
H. Cranial Nerves not covered previously	-	-	-
1. Trigeminal - Sensory of forehead, face,jaw (Closing of jaw)	-	-	-
2. Facial - raise eyebrows, wrinkle forehead, show teeth, smile, puff cheeks,	-	-	-
3. Accessory - shrugging shoulders head to shoulder, resist head to hands	-	-	-
I. Ears	-	-	-
1. Inspect outer ear, symmetry	-	-	-
2. Inspect/palpate pinna	-	-	-
3. Gross hearing, whisper test	-	-	-
4. Weber, Rinne	-	-	-
5. Otoscopic Exam: Describe land marks.(Cone of light, malleus, umbo)	-	-	-
J. Nose	-	-	-
1. Inspect: mucosa, septum deviation, symmetry, turbinates	-	-	-
2. Assess patency of nose	-	-	-
3. Palpate (external nose, sinuses, frontal & maxillary)	-	-	-
4. Test sense of smell	-	-	-
K. Mouth and Pharynx	-	-	-
1. Inspect mouth: Mucosa, gums and teeth	-	-	-
2. Inspect Tongue (sublingual also)	-	-	-
3. Tongue: motor/deviation	-	-	-
4. Inspect pharynx, Uvula/palate movement on phonation.	-	-	-
5. Sense of Taste	-	-	-

L. Neck	---	---	------------
1. Inspect neck (inc. R.O.M/strength)	-	-	-
2. Palpate trachea position	-	-	-
3. Palpate thyroid	-	-	-
4. Auscultate carotid	-	-	-
M. Lymph Nodes	-	-	-
1. Occipital	-	-	-
2. Post auricular / pre-auricular	-	-	-
3. Tonsillar	-	-	-
4. Submaxillary/Submandibular	-	-	-
5. Submental	-	-	-
6. Ant./Posterior cervical chains	-	-	-
7. Supraclavicular/Infraclavicular	-	-	-
8. Axillary	-	-	-
N. Posterior Thorax and Lungs (Sitting)	-	-	-
1. Inspect (contour, pattern, etc.)	-	-	-
2. Respiratory pattern	-	-	-
3. Palpate for respiratory expansion	-	-	-
4. Palpate fremitus-compare sides	-	-	-
5. Percuss lung fields	-	-	-
6. Percuss for diaphragmatic excursion	-	-	-
7. Auscultate lung fields	-	-	-
8. Costalvertebral rebound	-	-	-
O. Anterior, Thorax and Lungs (Sitting)	-	-	-
1. Inspect	-	-	-
2. Palpate for fremitus	-	-	-
3. Percuss lung fields	-	-	-
4. Auscultate lungs	-	-	-

P. Heart (Sitting)	----	----	----------------
1. Palpate for lifts, heaves or thrills, PMI	-	-	-
2. Auscultate (Bell/Diaphragm)	-	-	-
a. aortic (murmur)	-	-	-
b. pulmonic	-	-	-
c. Erb's point	-	-	-
d. tricuspid	-	-	-
e. mitral (count heartbeat)	-	-	-
Q. Heart (Supine)	-	-	-
1. (Observe JVD)Inspect for heaves/pulsations/thrills	-	-	-
2. Auscultate (Bell/Diaphragm)	-	-	-
a. aorta	-	-	-
b.pulmonic	-	-	-
c. Erb's point	-	-	-
d. tricuspid	-	-	-
e. mitral (murmur)	-	-	-
R. Abdomen	-	-	-
1. Inspect	-	-	-
2. Auscultate all four quadrants for Bowel sounds	-	-	-
3. Auscultate arteries (Aorta, Renal, Femoral)	-	-	-
4. Percuss: all four quadrants	-	-	-
5. Percuss spleen	-	-	-
6. Percuss liver	-	-	-
5. Palpate all four quadrants (Light/deep)	-	-	-
6. Palpate Liver	-	-	-
7 Palpate Spleen	-	-	-
8. Palpate Kidneys	-	-	-
9. Palpate Aorta	-	-	-
10. Palpate Femoral Pulse	-	-	-
11. Abdominal Reflex	-	-	-

S. Extremities (lower supine)	------	-----	-----------------------
1. Inspection/general	-	-	-
2. Palpate Pulses	-	-	-
a Popliteal	-	-	-
b. Dorsalis Pedis	-	-	-
c. Postereior Tibial	-	-	-
3. Sensory (light/deep, sharp/dull)	-	-	-
4. ROM of joints, position sense	-	-	-
5. Palpation of all joints	-	-	-
6. Strength	-	-	-
7. Reflexes	-	-	-
a. Achilles	-	-	-
b. Babinski	-	-	-
c. Patella	-	-	-
d. Homan's sign	-	-	-
e. Clonus	-	-	-
II. Organization (For more detailed explanation, Use Recommendations)	-	-	-
A. Uses correct vocabulary	-	-	-
B. Maintains privacy	-	-	-
C. Uses appropriate sequence	-	-	-
D. Examines thoroughly	-	-	-
E. Uses organized approach	-	-	-