Physical Assessment

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  1. Demonstrates All Throughout
    • *Prioritization of Patient Needs according to Maslow
    • *Provides thorough assessment of system(s) of focus/concern
    • Body Mechanics
    • *Saftey
  2. Apply principles of Aseptic Practice
    • * Hand Hygiene
    • PPE (personal protective equipment), as needed
    • Disposal of waste/gloves
  3. Introduction
    • *Introduce self and explain purpose and provides patient teaching as needed
    • *Identifies Patient
    • Provides for privacy and warmth
  4. General Survey
    • General survey of patient (pt postion, bed position, call light, posture, position, hygiene, grooming, dress, facial expression, mood, affect
    • Vs (TPR, BP, O2 Sat) Wt and Ht (as needed)
    • Age
    • Gender
    • *Environment (odors, temp, mobility aids, medical equipment, dressings, ostomies, tubes (like IVs), drains, etc.)
  5. Head and Neck Assessment
    • * Orientation x3/ LOC (level of consciousness)/ Cooperation/speech
    • Face/Skull/Scalp/Hair (if needed)
    • *Pupil size (mm; equal or unequal)
    • *PERRLA Pupils, Equal, Round, Reactive to light and accommodation
    • Vision Ability (if indicated)
    • Nares (epistaxis)
    • Ears/ hearing ability (if indicated)
    • Neck Vein Distention (jugular)
    • Mouth (oropharynx/mm)
    • Palpation of Lymph Nodes, if indicated
    • Palpation of carotid pulses, if indicated (one side at a time)
  6. Skin/Integumentary
    • *Color
    • *Turgor
    • *Temperature and Moisture
    • *condition
    • Description of Impairment
    • Inspect nails of feet and hands, if needed for cap refills, etc.
    • Check for clubbing, if needed
    • Inspect for skin on posterior surfaces checking for blanching of any reddened areas
    • *Note special equipment such as waffle mattress, heel/elbow guards, wound vac, etc.
  7. Cardiovascular Assessment
    • *Auscultation of the heart (at least 1 min. apically)
    • *Heart sounds, Rate, Rhythm, Loudness, Strength
  8. Chest and Lung Assessment
    • Appearance ( inspection, A-P diameter)
    • *Resp. Rate and Rhythm/Effort
    • Presence of cough (including characteristics and presence of sputum), if indicated
    • *Auscultation of lung sounds with all lung fields (6)
    • *Note equipment (O2, I/S, etc)
  9. GI/ Abdomen
    • Inspect Abdomen first
    • *Auscultate bowel sounds in all four quadrants; can discuss Active, Hypoactive, Hyperactive and Absent (if absent listen for bowels sounds in each quadrant that is absent)
    • Palpate (light), if indicated, noting any tenderness (notes general softness or firmness of abdomen)
    • *Assess Bowel habits
    • Observe for presence of emesis
    • Assess for incontinence of stool
    • *Note special equipment such as NG tube, G tube, J tube, feedings, ostomy, etc
  10. GU
    • Note usual voiding pattern
    • Observe for urinary incontinence and type
    • *Observe urine for color, odor, clarity, etc.
    • *Note special equipment such as F/C, urostomy, suprapubic cath, CBI
  11. Upper Extremities
    • Palpates pulses bilaterally, if indicated (brachial, Radial)
    • *Assess capillary refill
    • *Notes color, temp, edema, sensation, movement
    • *Assess grip strength
    • *Note special equipment
  12. Lower Extremities
    • Palpate pulses bilaterally (Femoral, Popliteal, *Dorsalis Pedis, *Posterior Tibial)
    • *Assess Cap Refill
    • *Notes color, temp, edema, sensation, movement
    • DTR's, if indicated (Patellar)
    • *Note special equipment (abduction pillow, cast, ted hose, cane, walker, etc.)
  13. Comfort
    *Assess pain, noting scale, description, location, and what makes better/worse
  14. Documentation
    *Completed with appropriate information
Card Set
Physical Assessment
physical assessment
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