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Actions

Questions to Patient

Report of Findings

Introduction
Gather equipment, knock on door and wash hands

Hello Mrs. Morrison, my name is Sianna and I will be your student nurse today. How are you doing today? Can I check your ID band? Can you tell me your name and date of birth? Do you have any allergies to any foods, medications or latex? I would like to do a physical assessment and ask you a few questions. Is not a good time? Good, I am going to provide us with some privacy. (pull curtain)
Pull up chair and position self at eye level with patient

How did you sleep last night? Do you have any concerns today? Now I am going to check your vital signs.
Take temp. Put cuff on one arm, pulse ox on the other and run machine while checking radial pulse and respirations.

Patients blood pressure is ___/___ on her right arm in the supine position. Radial pulse is ____, regular rate and rhythm. Oxygen saturation is ___% on room air. Respirations are ____ breaths per minute with regular rate and rhythm, non-labored. Oral temperature is ___F.
Are you having any pain today?

General Survey/Mental Status


Can you tell me your name again please? Do you know where you are right now? Do you know what day of the week it is?

Patient is A&O x3, oriented to person, place and time Patient appears to be well nourished with no apparent distress. Patient has good personal hygiene and no obvious body or breath odors. Affect and behavior are appropriate for the situation. Facial expressions are symmetrical and appropriate. Speech is clear and unimpaired.

Integument
Inspect skin for color, temp, moisture and texture; head, both arms and both legs with back of hands.

Skin color is appropriate to race. No obvious elevations in temperature noted. Skin is dry, warm and smooth. No skin lesions observed No tenting observed.

Actions

Questions to Patient

Report of Findings

Head, Eyes, Ears, Nose and Throat


Do you wear any corrective lenses?

Patient is wearing corrective lenses


Pull down eyelids and look at sclera and conjunctive with thumbs

Sclera is white and conjunctiva is clear. There is no erythema or drainage.


Look straight ahead please.
Check pupils for size and PERRLA with penlight. Shine light in each eye twice, checking for direct reaction and opposite eye reaction. Hold pen away, have patient look at it and bring it towards them to focus on.

Pupils are 3mm, equal, round, reactive to light and accommodation


Are you wearing any hearing devices?

Patient is not wearing any corrective hearing devices and responds appropriately to spoken word.
Inspect lips for symmetry, color, moisture or lesions.

Lips are symmetrical, pink, moist and without lesions.

Chest/Lungs Are you having any shortness or breath or cough?


Inspect chest for symmetry of movement and assess respiratory movement.

Respiratory pattern is regular and symmetrical. Effort appears to be non-labored with no obvious retractions or use of accessory muscles.
Auscultate anterior right and left breath sounds - 2nd intercostal space, mid-clavicular line, left and right Auscultate lateral breath sounds at 5th intercostal space anterior to mid-axillary line - where the breast starts (in line with nipple) Auscultate posterior right and left breath sounds in a butterfly pattern, snake back and forth - 6 locations starting above clavicle

There are no obvious wheezes, rhonchi, crackels, rubs or stridor, bilaterally

Heart
Are you having any chest pains? Do you feel like your heart is pounding or beating irregularly?
Auscultate apical pulse at apex, 5th intercostal space, can be over breast tissue - nipple - diaphragm and bell

Apical pulse has regular rate and rhythm with no obvious murmurs, gallops or rubs
Check capillary refill on both hands and feet

Capillary refill is less than 2 seconds

Actions

Questions to Patient

Report of Findings

Abdomen
Are you having any nausea, vomiting, diarrhea, constipation or problems with urination?
Inspect contour of abdomen

Abdomen is flat and equal bilaterally


Auscultate bowel sounds in all 4 quadrants with the diaphragm

Bowl sounds are present in all 4 quadrants


Can you please bend your knees for me? I am going to press on your stomach a bit, let me know if you feel any tenderness or pain.
Palpate abdomen lightly in a circular motion with fingertips, hitting all 4 quadrants

No tenderness or rigidity noted with light palpation


Palpate abdomen deeply with one hand on the other, hitting all 4 quadrants

No tenderness, organomegaly or masses noted with deep palpations

Neuromuscular/Peripheral Vascular
Are you having any numbness or tingling? Are you having any calf pain?
Inspect upper and lower extremities for muscle wasting

Upper and lower extremities appear to be without muscle wasting


Can you grasp my fingers with both hands? Can you push your feet against my hands?

Grip strength and foot pushes are 5/5 bilaterally.

No weakness or tremors noted.


Inspect lower leg and foot for edema

No pretibial or pedal edema is noted


Palpate dorsalis pedis pulse

Dorsalis pedis pulse has a 2+ regular rate and rhythm bilaterally


Can you wiggle your toes? Tell me when you can feel me touching your toes.

Movement and sensation of toes are intact bilaterally. Toes are pink and warm to touch bilaterally.
Assess calves

Calves are without erythema, edema or heat

IVs, Drains, Dressings/TED, ect.

Actions

Questions to Patient

Report of Findings

There are no IV sites or pumps, no medical equipment, no incisions or wounds present, and no apparent drains or TED hose.

Thank you Mrs. Morrison, your assessment is complete. Do you have any questions?

Focused Cardiovascular
Can you tell me your name again please? Do you know where you are right now? Do you know what day of the week it is?

Patient is A&O x3, oriented to person, place and time


I need to take your vital signs Instructor will say vital signs have been taken Are you having any chest pain? Do you feel like your heart is pounding or beating irregularly?
Inspect skin and lips for color

Skin and lips are pink, no erythema or cyanosis noted


Auscultate anterior right and left breath sounds - 2nd intercostal space, mid-clavicular line, left and right Auscultate lateral breath sounds at 5th intercostal space anterior to mid-axillary line - where the breast starts (in line with nipple) Auscultate posterior right and left breath sounds in a butterfly pattern, snake back and forth - 6 locations starting above clavicle

There are no obvious wheezes, rhonchi, crackels, rubs or stridor, bilaterally


Auscultate 5 areas of pericardium - diaphragm and bell Aortic - right side 2nd intercostal, close to sternum Pulmonic - left side 2nd intercostal, close to sternum Erbs - left side 3rd intercostal, close to sternum Tricuspid - left side 4th intercostal, close to sternum Mitral - left side 5th intercostal, mid-clavicular line; over nipple area

Heart rate and rhythm are regular with no murmurs, gallops or rubs
Assess pulse deficit by listening to apex at 5th intercostal, mid-clavicular line; nipple area, while checking radial pulse

No obvious pulse deficit


Assess for jugular venous distention by lying flat, asking the patient to look to the left and raise bed to 45 degree angle, watching jugular disappear

No obvious jugular venous distention


Assess for pre-tibial and pedal edema

No pre-tibial or pedal edema noted


Assess color and capillary refill of index finger and big toe bilaterally

Capillary refill in extremities is less than 2 seconds bilaterally

Thank you Mrs. Morrison, your assessment is complete. Do you have any questions?

Actions

Questions to Patient

Report of Findings

Focused Respiratory
Can you tell me your name again please? Do you know where you are right now? Do you know what day of the week it is?

Patient is A&O x3, oriented to person, place and time


I need to take your vital signs Instructor will say vital signs have been taken Do you have any shortness of breath? Do you have any chest pain with breathing? Do you have a cough? patient will say yes Is it productive? patient will say yes and had you sputum
Assess sputum

There is ____ amount of sputum that is ____(thick, watery, frothy) and ___in color
Inspect skin and lips for color

Skin and lips are pink, no erythema or cyanosis noted


Inspect trachea for midline placement

Trachea is midline
Inspect chest for symmetry of movement and configuration

Symmetrical movement of chest with no abnormalities of configuration


Assess respiratory effort

No obvious retractions or use of accessory muscles


Auscultate anterior right and left breath sounds in 8 locations starting above the clavicle in a butterfly pattern and snake back and forth Auscultate lateral breath sounds in 4 locations on each side starting in anterior armpit, 2nd intercostal, 4th intercostal and 5th intercostal, moving anterior for right side for middle lobe Auscultate posterior right and left breath sounds in 10 locations starting above clavicular line, using a butterfly pattern and snake back and forth

Breath sounds are symmetrical with no obvious signs of wheezes, ronchi, crackles, rubs or stridor
Percuss lung fields for dullness in 10 posterior locations, same as auscultation locations

No obvious areas of dullness


Auscultate heart sound at the apex, 5th intercostal mid-clavicular line; nipple area with bell and diaphragm

Heart rate and rhythm are regular with murmurs, gallops or rubs
Inspect fingers for clubbing

No clubbing observed

Actions

Questions to Patient

Report of Findings

Thank you Mrs. Morrison, your assessment is complete. Do you have any questions?

Focused Neuro
Can you tell me your name again please? Do you know where you are right now? Do you know what day of the week it is?

Patient is A&O x3, oriented to person, place and time


I need to take your vital signs Instructor will say vital signs have been taken

Patient appears to be well nourished with no apparent distress. Patient has good personal hygiene and no obvious body or breath odors. Affect and behavior are appropriate for the situation. Facial expressions are symmetrical and appropriate. Speech is clear and unimpaired
Look straight ahead please.
Check pupils for size and PERRLA with penlight. Shine light in each eye twice, checking for direct reaction and opposite eye reaction. Hold pen away, have patient look at it and bring it towards them to focus on.

Pupils are 3mm, equal, round, reactive to light and accommodation


Can you lift your eyebrows? Smile? Frown? Puff your cheeks out?

Cranial Nerve 7 is intact


Can you open your mouth and say ahhh?
Use light to look at uvula

Cranial Nerves 9 & 10 are intact with rise of uvula


Can you stick out your tongue?

Cranial Nerve 12 is intact. Tongue is midline with no tremors


Can you grab my finger?

Patient is able to follow a one-step command


Can you squeeze both of my hands? Can you push your feet against my hands?

Muscle strength is appropriate for situation Hand grasps and foot pushes are 5/5 bilaterally
Do you have any numbness or tingling in your fingers or toes? Close your eyes and tell me when you feel me touch your fingers

Actions

Questions to Patient

Report of Findings

Now tell me when you feel me touch your toes

No parasthesia noted in fingers or toes

Thank you Mrs. Morrison, your assessment is complete. Do you have any questions?