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Name_____________________________________ Date ________________________

Youngstown State University

Department of Nursing
NURS 2643 Health Assessment
Physical Examination and Documentation Final

Equipment List: Stethoscope, pupil stick, tongue blade, gloves, penlight, reflex hammer, bedside lamp.

ASSESSMENT SKILL EXAM CHART NOTES

GENERAL SURVEY/ MENTAL SITTING

STATE
General Appearance 1 1 Alertness, Behavior, Mood, Speech, etc.
Orientation 1 1 Person, Place, Time
Comfort/Pain level 1 1 Pain scale
SKIN/NAILS
General Skin 1 1 Inspect/Palpate
Temperature/Moisture 1 1 Palpate – face, neck, upper extremities, thorax
Turgor 1 1 Palpate (clavicular area)
General Nails/Nailbeds 1 1 Inspect (fingernails)
Clubbing 1 1 Inspect (fingernails)
Capillary Refill 1 1 Palpate (fingernails)
HEAD /FACE
General Head/Scalp 1 1 Inspect/Palpate
General Face 1 1 Inspect/Palpate
Temporal Pulse 1 1 Palpate
EYES
General Eyes 1 1 Inspect
Eyelids, lashes, brows 1 1 Inspect/Verbalize and document structures
Conjunctiva, sclera, iris 1 1 Inspect/Verbalize and document structures
Cornea, pupils 1 1 Inspect/Verbalize and document structures, pupil size
Pupillary reaction 2 2 Direct light response, Accommodation
EARS
General Ears 1 1 Inspect
Pinna, lobule, tragus 1 1 Inspect/Palpate/Verbalize and document structures
Mastoid process 1 1 Inspect/Palpate/Verbalize and document structures
Auditory meatus 1 1 Inspect (penlight)
NOSE
General Nose 1 1 Inspect
Mucosa/Septum 1 1 Inspect (penlight)
Nares (patency) 1 1 Palpate
MOUTH
General Mouth/Lips 1 1 Inspect/Verbalize and document structure
Teeth, gums, buccal mucosa 1 1 Inspect (penlight, tongue blade)/Verbalize and
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document structures
Tongue, sublingual area 1 1 Inspect (penlight)/Verbalize and document structures
Hard palate, soft palate 1 1 Inspect (penlight)/Verbalize and document structures
Tonsils, uvula 1 1 Inspect (penlight)/Verbalize and document structures
HEAD/NECK
General Neck 1 1 Inspect/Palpate
Carotid Pulses 1 1 Palpate
Carotid Bruits 1 1 Auscultate
LYMPH NODES
Pre-auricular 1 1 Palpate/Verbalize and document structure
Post-auricular 1 1 Palpate/Verbalize and document structure
Occipital 1 1 Palpate/Verbalize and document structure
Jugulodigastric 1 1 Palpate/Verbalize and document structure
Submandibular 1 1 Palpate/Verbalize and document structure
Submental 1 1 Palpate/Verbalize and document structure
Anterior Cervical 1 1 Palpate/Verbalize and document structure
Posterior Cervical 1 1 Palpate/Verbalize and document structure
Deep Cervical 1 1 Palpate/Verbalize and document structure
Supraclavicular 1 1 Palpate/Verbalize and document structure
THORAX/RESPIRATORY
General Thorax 1 1 Inspect/Palpate, respiratory character, AP diameter
Chest Expansion – Anterior 1 1 Inspect/Palpate
Chest Expansion - Posterior 1 1 Inspect/Palpate
Breath Sounds – Posterior 1 1 Auscultate
Breath Sounds – Lateral 1 1 Auscultate
Breath Sounds - Anterior 1 1 Auscultate
CARDIAC
General Precordium 1 1 Inspect (bedside lamp)
Apical Impulse 1 1 Inspect/Palpate (bedside lamp)
Aortic (bell/diaphragm) 2 2 Auscultate/Verbalize valve and location/Document valve
Pulmonic (bell/diaphragm) 2 2 Auscultate/Verbalize valve and location/Document valve
Tricuspid (bell/diaphragm) 2 2 Auscultate/Verbalize valve and location/Document valve
Mitral (bell/diaphragm) 2 2 Auscultate/Verbalize valve and location/Document valve
Jugular Vein 1 1 Inspect for JVD (45° angle)
ABDOMEN SUPINE
General Abdomen 1 1 Inspect (bedside lamp), leg rest up
Contour and Symmetry 1 1 Inspect from side of bed and foot of bed
Bowel Sounds/4 quadrants 1 1 Auscultate
Percuss/4 quadrants 1 1 Percuss
Palpation/4 quadrants 1 1 Palpate (light palpation only)
PERIPHERALVASCULAR
General PV 1 1 Inspect/Palpate – upper and lower extremities
Temperature 1 1 Palpate – lower extremities
Pitting Edema 1 1 Palpate - pre-tibial area
General Nails/Nailbeds 1 1 Inspect (toenails)
Capillary Refill 1 1 Palpate (toenails)
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PERIPHERAL PULSES
Brachial 1 1 Palpate/Verbalize and document structure
Radial 1 1 Palpate/Verbalize and document structure
Popliteal 1 1 Palpate/Verbalize and document structure
Posterior Tibial 1 1 Palpate/Verbalize and document structure
Dorsalis Pedis 1 1 Palpate/Verbalize and document structure
NEUROMUSCULAR
General Musculoskeletal 1 1 Inspect/Palpate – muscles, joints
ROM/STRENGTH
LOWER BODY
Hip ROM 1 1 Flex (leg raise), abduct, adduct, internal/external rotate
Knee ROM 1 1 Flex knee to chest (knee and hip flexion)
Ankle ROM 1 1 Plantar flex, dorsiflex, invert, evert
Toes ROM 1 1 Flex and extend toes
SITTING
Leg Strength/feet 1 1 Observe with resistance
Leg Strength/thigh and calf 2 2 Observe with resistance and against gravity
ROM/STRENGTH
UPPER BODY ROM
Head and Neck ROM 1 1 Flex, hyperextend, lateral bend, rotate
Head and Neck Strength 1 1 Observe with resistance
Elbow ROM 1 1 Flex, extend
Wrist ROM 1 1 Flex, hyperextend
Fingers ROM 1 1 Flex, extend
Arm Strength /upper arm 2 2 Observe with resistance and against gravity
and forearm
Arm Strength/Hand Grasps 1 1 Observe
STANDING
Shoulders ROM 1 1 Flex, hyperextend, abduct/adduct, int/ext rotate
Shoulders Strength 1 1 Observe with resistance
SPINE
Spine 1 1 Inspect/Palpate
Spine ROM 1 1 Flex, hyperextend, lateral bend, rotate
NEURO
Tandem Walking 1 1 Observe balance, coordination, gait
Romberg Test 1 1 Observe
SITTING
Patellar Reflex 1 1 Observe (reflex hammer)
Motor Coordination –upper 1 1 Observe – one test of upper body coordination
Motor Coordination – lower 1 1 Observe – one test of lower body coordination
TOTAL POINTS ATTAINED

GENERAL CRITERIA See General Criteria (below)

DEDUCTION (IF ANY) (0 to -10 points)
FINAL GRADE POINTS

GENERAL PHYSICAL EXAM AND DOCUMENTATION CRITERIA
PHYSICAL EXAM CRITERIA
Prep: Prepares patient in advance of exam
(shirt, shoes off), knows how to operate exam
table, etc.
Prep: Prepares work area in advance of exam
(patient’s clothing, coats, shoes, etc. out of
work area)
Hand hygiene: Washes hands prior to exam
and uses hand sanitizer as needed
throughout exam.
Appearance: Dresses appropriately and
professionally (long hair up or back, no gum
chewing, no blue jeans)
Professionalism: Professional language and
behavior, introduces self as student nurse,
introduces patient to instructor
Overall organization: Orderly, connected,
flows
Interaction: Appropriate
interactions/instructions
Safety: Actions to ensure client safety as
needed
Comfort: Actions to ensure client comfort as
needed (pulls leg rest out when needed, etc.)
Privacy: Actions to ensure client privacy
Technique: performs assessment techniques
correctly and confidently and uses equipment
(ex: penlight) correctly and when necessary
Verbalizes assessment: States required
assessment and correct pronunciation
Medical terms: Verbalizes correct medical
terms
Within time limit: Within 30 minute time limit
4
-pts DOCUMENTATION CRITERIA -pts
Phraseology: Uses appropriate charting
phraseology
Neatness: Legible and easy to read
Use of med. terms: Appropriate use of
medical terms
Accurate: Charts areas assessed with
accuracy
Missing items: Clearly indicates any areas
charted but not assessed (in parenthesis)
Clear: Easy to understand
Concise: Detailed findings but to the point
Adequate detail: Charting adequate depth
of findings
Appropriate abbrev.: Use of correct
medical abbreviations, uses abbreviation
instead of patient’s name (if documented)
Making corrections: Errors corrected with
single line through error
Overall organization: Organized
appropriately and flows
Required documentation: charts required
structures in appropriate sections (ex:
chart all lymphnode names, heart valves,
etc.)
Spelling: No or minimal spelling errors
Within time limit: Within 30 minute time
frame
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clbosley 12/13/16