Physical Assessment Eval Form Student C

Physical Assessment
Required Components
Nursing Process

Required Components

General survey
1. General appearance & behavior
2. Posture
3. Gait
4. Hygiene
5. Speech
6. Mental Status
7. Vital Signs
8. Nutritional Status

Head and Neck
1. Symmetry
2. Head & hair
3. Ears/Hearing
4. PERRL(A)
5. EOM
6. Convergence/Accommodation
7. Color/condition conjunctiva
8. Color/condition of mucus membranes
9. Nose
10. Mouth/teeth
11. ROM of neck
12. Cervical nodes
13. Palpate trachea for symmetry
14. Carotids, auscultate optionally
15. JVD

Upper extremities
1. Skin – condition,
2. Palpate for temperature, sensation, muscle tension/firmness
3. Capillary refill
4. Turgor
5. Pulses
6. Strength
7. ROM

Thorax/
Respiratory
1. Inspect Thoracic expansion, symmetry
2. Inspect respiratory pattern
3. Palpate for tenderness, symmetry, and fremitus
4. Auscultate normal & abnormal sounds
5. Auscultate breath sounds (identify areas for normal breath sounds A & P)
6. Discuss anatomy

Cardiac
1. Inspect for abnormal pulsations
2. Palpate PMI
3. Auscultate heart sounds, identify sites, normal sounds, terminology
4. Discuss anatomy

Abdomen
1. Inspect for symmetry, pulsations, bladder distention
2. Auscultate for Bowel Sounds X 4
3. Light palpation for surface lumps or nodules
4. Discuss/demonstration assessment for abdominal pain
5. Discuss underlying anatomy

Lower Extremities
1. Inspect Skin – condition, hair distribution.
2. Palpate for temperature, sensation, muscle tension/firmness
3. Capillary refill
4. Pulses
5. Pedal and Ankle Edema
6. Strength, dorsal and plantar flexion
7. ROM
8. Homan’s Sign