Physical Assessment Outline

Prep It In: Wash Hands

Check equipment
Knock before entering

Talk it: Greet the client, introduce self:

“Hi my name is _____ and I am going to be your nurse today”

Shake the clients hand:

Assess skin temperature, texture, moisture
Check the client wrist band: to confirm client

Draw Curtain

Tell client that you have some questions for them, and these questions are
going to be re-asked periodically

-Neuro: ask client their:

Name
DOB
Situation (Where they are, how they got here)
Todays Date

Prep it out: Explain, PA to client; raise bed

“Today I am going to compete a physical assessment, are you
having pain anywhere you want me to be aware of, have you had
any surgery or complications that may bother you during this
assessment”

Take clients V/S

Pulse
Strength: 0=absent, 1+=thready, 2+=normal, 3+= bounding
Rate: Regular, irregular
Respirations
Rate:
Effort: labored, unlabored
Temperature
B/P

Review it: Ask clients about body systems from the head to the toe
Head: look over the clients hair
Ask about: Headaches
 Vision troubles
Hearing troubles
Breathing (nose and the mouth) troubles
Eating troubles
Swallowing troubles

Respiratory: Breathing troubles

Pain
Coughing
Sputum: color, amount, consistency,
frequency
Oxygen: type, amount

Cardiac: Chest pains

Troubles when standing
Pain

MSK: Pain in the arms, legs, feet

GI: Abdomen pain

GU: Stool: color, consistency, density, oder

Urine: color, oder, discomfort
LBM: Last Bowel Movement
LMC: Last Menstrual Cycle

Skin(Integ): Rashes, Cuts, Bruises, lesions

Do It: Head: Cardiac: Bilateral Temporal Arteries

Integ: Assess behind Ears

Neuro: Vision Test

PERRLA: Pupils equal, round, reactive to light,
accommodate
Dilation, constriction, accommodation with penlight:
both eyes (note mm before and after)
Conjuctivia: Pink Mucosa
Mouth: Pink mucosa

Neck: Integ: Trachea

Thyroid
 Cardiac: Carotid arteries bilaterally

MSK: Movement of neck

Spine: C7

Chest: Cardiac: Auscultate heart sounds: Aortic 2R, Pulmonary 2L,

Tricuspid 4L, Mitral 5L, Apical - Midcalvical
Apical Pulse: 60 secs

Respiratory: Auscultate lung sounds

Anterior, posterior and laterally

MSK: Inspect Spine

Arms: Neuro: Movement in joints

Strength in hands

` Cardiac: Brachial arteries

Radial arteries

Integ: CRT > 3 seconds

Turgor

GI: Integ: Inspection

Abdomen:
Auscultate, light & deep palpatation
4 quads; 4-32 sounds/quad)
Bladder: inspect, palpate

Legs: Cardiac: Femoral arteries

Popetial arteries

MSK: Movement of joints

Homan’s Sign
Strength of feet:
Pushes and Pulls

Cardiac: Tibias arteries

Pedal arteries
CRT bilaterally

Integ: Sensation on toes

Check for Edema on Legs
** Help get up and walk over to the weight and height stand.

Check: Gait
Affect
Strength
Weight
Height

End it: Assess Client visually

Draw-back curtain
Place call-button close
Lower Bed
Provide client with any further needs.

Doc it: Complete Assessment