UNIVERSITY OF LA SALETTE COLLEGE OF NURSING CLINICAL EVALUATION TOOL PHYSICAL ASSESSMENT PERFORMANCE CHECKLIST NAME OF STUDENT: __________________________ DATE

: ____________ YEAR/SECTION: ______________________________ SCORE: ___________ RATING SCALE 1 : not done or incorrectly done 3 : correct measures, but with inadequate description of findings; or not systematic In performance 5 : correctly done, systematic according to standard; with correct findings NA : not applicable PARAMETERS 1 A. GENERAL PHYSICAL SURVEY I. Observe appropriate guidelines for physical assessment a. Greets client appropriately b. Identifies self c. Explains the procedure d. Provides privacy e. Assists client in comfortable position II. Assess the following a. physical development, behavior, mood/affect, dress, grooming/hygiene, gait, body build b. vital signs BP ______ PR ______ RR ______ Temp ______ c. height: _____________ weight: _____________ d. pain yes _____ no ______ if yes, identifies COLDSPA of pain e. mental status B. INTEGUMENT I. Skin a. Inspects for general color variations, skin breakdown, lesions b. Palpates for presence of lesions, for texture, temperature, mobility, turgor, edema II. Scalp and Hair a. Inspects, color, amount and distribution b. Inspects and palpates for thickness, texture, oiliness, lesion, parasites III. Nails a. Inspects for grooming and cleanliness, color, markings and shape b. Palpates for texture and consistency c. Tests for capillary refill C. HEAD AND NECK I. Head and Face a. Inspects head for size, shape, masses, lesions b. Palpates head for consistency, presence of lesions SCORE0 3 5 N A REMARK S

mobility. Sinuses a. positioning of eyeballs. posture while breathing b. shape. ABDOMEN a. Inspect size. Heart a. shape. Perform light then deep palpation e. consistency. masses III. Perform the following test: . Performs vision test b. features. lesions. Auscultate for breath sounds. Percuss for tone d. lesions. Inspect for color variations. eyelashes. sclera.c. lesions IV. Posterior and Anterior Thorax a. EYES a. Throat a. Performs the RInne test e. THROAT. position. lesions c. Inspects for size. Palpate auricles for tenderness c. Inspect tonsils for color. color b. Inspects face for symmetry. Palpate for tenderness G. conjunctiva. movement. discharge b. consistency. pupil d. adventitious breath sounds II. Inspects eyelids. vascularity. Inspects for color. Neck a. fremitus. tissue consistency. tenderness. iris. grading scale III. EARS a. bleeding. MOUTH. consistency b. NOSE. Mouth a. Performs the Romberg test F. Inspects neck for position. Inspects and palpates the thyroid gland. discoloration. Tests pupillary reaction to light e. skin condition II. moisture. Auscultate for bowel sounds c. Nose a. patency. Inspect for color. Performs extraocular muscle function test c. SINUS I. auscultates for bruits sound (if gland is enlarged) c. Notes any distinctive odors b. Performs the Weber test d. rhythm H. cornea. contour b. presence of lumps/masses b. elasticity. symmetry. Auscultate heart sounds for rate. Inspect for color. Breast a. teeth II. Palpates lymph nodes for size. gums. lesions. symmetry. Inspect for shape. swelling. Palpate for tenderness. Palpate for texture. consistency and tenderness D. THORAX AND LUNGS/CHEST I. shape. Tests accommodation of pupils E. chest expansion c. expression. lesions/masses. Inspect. use of accessory muscle.

Palpate for tenderness. Rectum and Prostate a. nodules. Palpate texture. Tests for appendicitis iv. swelling.i. PROSTATE I. Test for cholecystitis I. lesions. lesions b. bulges c. lumps. shape. temperature c. irregularities c. Inspect excoriation. Ballottement test iii. Inspect for inguinal and hiatal hernia K. Test condition and movement of muscles d. Palpate pulses J. size. ulcers. infestation. Test for ROM II. Inspect feces for blood L. Fluid wave test ii. rashes. RECTUM. Inspect scrotum for swelling. hardness b. Inspect for rectal prolapsed with Valsalva maneuver II. Male Genitalia a. irregularities. excoriation and discharge b. Inspect for lesion. shape. color. GENITALIA I. Test coordination f. For males. OTHERS (if appropriate) I. Glasgow Coma Scale b. Inspect for color. Inspect for size. infestation. palpate the prostate gland for tenderness. EXTREMITIES a. Musculoskeletal a. tenderness. rashes. Cranial nerves c. Female Genitalia a. lesions b. Test balance e. redness b. Test reflexes ______________________________________ CLINICAL INSTRUCTOR’S NAME AND SIGNATURE . ANUS. Anus and Perianal Area a. Inspect for lumps. Neurologic a. texture. Perform speculum examination II. nodules b. symmetry. symmetry. swelling.

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