General & Head,Face, Neck
State the initial steps when establishing care before starting the physical assessment.
What are introduce yourself, obtain 2 patient identifiers and hand hygiene (wash your hands)?
What is otoscope and brace safely with otoscope?
State the client positioning required for posterior thorax, anterior thorax and the heart & neck vessels assessments?
What is high Fowler's for posterior thorax, semi Fowler's for anterior thorax, and semi Fowler's for heart & neck?
You must palpate the spinous processes from C1 down to this lowest section of the vertebral column for tenderness.
What is the coccyx?
This mandatory final step of the entire practical examination involves discarding your speculums and tongue blades and performing hand hygiene.
What is infection control?
State four items you can choose to include when stating: "In the general survey I will be assessing..."
What are any four of: client's stated age, level of consciousness, facial expression, skin color, posture & position, dress & personal hygiene, mood & affect, speech, or mobility & gait?
Perform the inspection and tests of the ears section.
What is inspection:
Inspect auricles & surrounding tissue
for (2): size, shape, lumps, lesions
Tests/Special:
Otoscopy: Inspect external canal for
(2): foreign bodies, cerumen,
discharge, redness, swelling, lesions
Otoscopy: Inspect tympanic
membrane for (2): color, landmarks,
position of cone of light
Safely brace with otoscope
To properly auscultate for normal or abnormal heart sounds in this valve area, you must identify its anatomical location at the left fifth intercostal space along the midclavicular line. This is also the exact site where you palpate the apical pulse.
What is the mitral valve?
According to the rubric's parameters, you must auscultate in all four quadrants and verify the frequency and character of bowel sounds, but you must persist with your stethoscope over the abdomen for this exact duration before you can state that bowel sounds are absent.
What is 5 minutes?
To properly complete your lower extremity assessment, you must locate and grade both of these specific pedal pulses.
What is the dorsalis pedis pulse and the posterior tibial pulse?
What is testing facial nerve - ask patient to (2): smile, frown, lift eyebrows, show teeth, puff out cheeks?
What is testing ROM of TMJ: State, “I am observing for pain, crepitation, and limited ROM.”?
What is testing ROM of TMJ: open & closes mouth, protrusion, side-to-side motion?
Perform the palpation & tests of the nose section.
What is Palpation:
Palpate frontal sinuses for tenderness
Palpate maxillary sinuses for
tenderness
Tests/Special:
Test for nasal patency
Use otoscope to inspect mucosa for
(2): color, swelling, discharge,
bleeding, polyps
Use otoscope to inspect septum for
(2): perforation, deviation, bleeding
Safely brace with otoscope
Perform the complete heart and neck vessels assessment
Inspection- Client in semi-fowlers, no pillow, drape appropriately; Inspect neck for arterial / venous pulsations, & distention (must use a pen light)
Palpation- Palpate the carotid arteries (one at a time) for rhythm & grade on a scale from 0 to 3+; Identify and palpate to the anatomic location of valve areas: aortic, pulmonic, tricuspid, mitral; Identify & palpate the anatomic location of the apical pulse
Auscultation- Identify where S1 & S2 are heard, Auscultate: aortic, pulmonic, tricuspid, & mitral valve areas for normal or abnormal heart sounds; Auscultate the apical pulse for one full minute and state the rate; Identify anatomical locations of: bronchial/tracheal, bronchovesicular, & vesicular breath sounds
When inspecting the spine from the side and back during the physical exam, you are specifically checking for symmetry and these three distinct spinal curvature conditions.
What is scoliosis, kyphosis, and lordosis?
Perform the additional neurological assessment
Assess tandem walk
Perform Romberg test for 20 seconds
Nurse stands next to client with arms in front & back of client for Romberg test
Perform the palpation section of the neck in the head to toe.
What is palpating sternocleidomastoid & trapezius for (state all): firmness, tenderness, and muscle spasm?
I will palpate lymph nodes for enlargement & tenderness. Palpate lymph nodes: pre-auricular, post-auricular, occipital, tonsillar, submandibular, submental, superficial cervical, deep cervical, posterior cervical, supra-clavicular.
Perform the mouth section of the Head to toe.
What is inspecting the lips for (2): color, moisture,
cracking, lesions?
Inspect gums for (2): color, swelling,
ulcerations, retraction of gingival
margins, bleeding
Inspect teeth for (2): discoloration,
missing, abnormal position
Inspect tongue for (2): color, moisture,
surface characteristics, nodules,
ulcerations
Inspect hard & soft palate for (2):
color, architecture, lesions
Inspect tonsils for (2): presence,
symmetry, size/enlargement
Inspect uvula for position and
movement
Use light source & tongue blade for
entire mouth exam
Perform the complete assessment of the posterior thorax
Inspection- Drape appropriately, patient in high-Fowler's; Inspect thorax for (2): muscle retraction, skeletal deformities, shape; Inspect skin for (2): color, condition, hair distribution, lesions
Palpation- Palpate chest wall/skin for (2): tenderness, crepitus, masses, temperature, texture, moisture, turgor
Percussion- Percuss for CVA tenderness
Perform the complete assessment of the spine
Inspection- Client standing, drape appropriately; Inspect spine from side & back for: symmetry, scoliosis, kyphosis, lordosis
Palpation- Palpate spinous processes from C1 to coccyx for tenderness; Palpate paravertebral muscles down the full length of the spine for tenderness & muscle spasm
Tests/Special- Test ROM of spine state: "I will observe for pain, crepitation, and limited movement."; Test ROM of spine: flexion, extension, lateral bending, rotation
Perform the complete lower extremities assessment
Inspection
Drape appropriately; Inspect skin of lower extremities for (2): color, condition, lesions, hair distribution, venous pattern; Inspect hips, knees, ankles, feet, heels, toes for (2): symmetry, swelling, deformity, size, contour; Inspect toenails for color & condition
Palpation- Palpate skin of lower extremity for (2): temperature, texture, moisture, turgor, edema; Palpate hips, knees, ankles, feet, heels, & toes for (2): swelling, heat, tenderness, masses; Palpate toenails for capillary refill; Palpate dorsalis pedis pulses for rhythm & state it is graded on a scale from 0 to 3+; Palpate the medial malleolus, then locate and assess the posterior tibial pulse for rhythm. Grade the pulse on a 0-3+ scale.
Tests/Special- Test ROM of lower extremity-state: "I will observe for pain & limited movement."; Test ROM of hips: flexion, extension, abduction, adduction, internal rotation, external rotation; Test ROM of the knees: flexion, extension; Cup bilateral knees through I full ROM for crepitation; Test ROM of the ankles: dorsiflexion, plantar flexion, inversion, eversion; Test strength of the hips: flexion against resistance; Test strength of the knees: flexion & extension against resistance; Test strength of ankles: dorsiflexion & plantar flexion against resistance; Deep tendon reflex: patellar and state it is graded on a scale of 0 to 4+; Plantar reflex
Perform the complete head and face assessment
Inspection- Inspect skull for size and shape; Inspect the scalp for scaliness and lesions; Inspect the hair for color, quantity, and distribution; Inspect the face for (2) expression, symmetry, involuntary movements, swelling; Inspect facial skin for color, condition, hair distribution, lesions; Inspect TMJ for swelling
Palpation- Palpate head/skull for lumps; Palpate TMJ for tenderness
Tests- Test facial nerve by asking the patient to smile, frown, lift eyebrows, show teeth, puff cheeks; Test ROM of TMJ by stating "I am observing for pain, crepitation, and limited ROM; Test ROM of TMJ by having the pt open and close mouth, protrude, and move jaw side to side
Perform the complete eye assessment
Inspection- Inspect eyebrows for symmetry, scaliness, and lesions; Inspect eyeballs for alignment and symmetry; Inspect eyelids for (2) position, palpebral fissure width, edema, color, lesions, distribution and direction of lashes; Inspect sclera and palpebral conjunctiva of lower lids for (2) color, lesions, swelling; Inspect pupils for size, shape, and quality; Inspect cornea and lens for opacities using oblique lighting
Tests- Test direct and consensual pupillary reaction to light; Test for accommodation; Test near vision by having pt read available print; Test symmetry of alignment with corneal light reflex; Perform cover test to detect degree of deviated alignment; Perform diagnostic positions including convergence to test extraocular movement, Test for red reflex
Perform the complete assessment of the anterior thorax
Inspection- Drape appropriately, patient in semi-fowlers; Note respiratory effort by observing facial expression; Inspect anterior thorax for muscle retractions, skeletal deformity
Palpation- Palpate chest wall/skin for (2): tenderness, crepitus, masses, temperature, texture, moisture, turgor
Auscultation- Identify anatomical locations where you hear: bronchial/tracheal, bronchovesicular, & vesicular sounds; Start at the lung apices and move systematically from side to side in a ladder-like pattern, covering the anterior chest. A minimum of 4 paired listening areas required.
Perform the complete abdominal assessment
Inspection- Client supine, draped appropriately, nurse standing on right side of client; Inspect abdomen from top and side for (2): contour, symmetry, movement, localized bulging, visible masses; Inspect umbilicus for (2): discoloration, location, inflammation, bulges
Auscultation- Auscultate all quadrants for frequency & character of bowel sounds; State that you would listen for a full 5 minutes over abdomen before stating bowel sounds are absent
Percussion- Percuss abdomen in all 4 quadrants for tympany and dullness
Palpation- Ask client if abdomen is tender; Perform light palpation in all 4 quadrants for tenderness, superficial masses, & guarding
Tests/Special- Maintain the correct order of the abdominal assessment
Perform the complete upper extremity assessment
Drape appropriately, client in high Fowler's
Inspection- Inspect the skin of the upper extremities for (2) color, condition, lesions, hair distribution, venous pattern; Inspect shoulder, elbows, wrists, hands, fingers, and thumb for symmetry, swelling, deformity, size, and contour; Inspect fingers for clubbing, lesions, and color
Palpation- Palpate the skin of the upper extremities for (2) temperature, texture, moisture, turgor, and edema; Palpate shoulder, elbows, wrists, hands, fingers, and thumbs for swelling, heat, tenderness, and masses; Palpate for capillary refill
Tests- Test ROM of upper extremity and state "I will be observing for pain and limited movement"; Test ROM of the shoulders with flexion, extension, abduction, adduction, internal rotation, external rotation; Test ROM of the elbow with flexion, extension, supination, and pronation; Cup bilateral shoulders or elbows through 2 ROMs for crepitation; Test ROM of the wrists with flexion, extension, radial deviation, and ulnar deviation; Test ROM of the metacarpal phalanges with flexion, extension, and hyperextension; Test ROM of the fingers with flexion, extension, abduction, and adduction; Test ROM of the thumb by opposition; Test the strength of the shoulder and shrug against resistance; Test strength of the elbow with flexion against resistance; Test strength of wrists with flexion and extension against resistance; Test strength of fingers with hand grip strength