San Pablo Colleges

Colleges of Nursing
San Pablo City

Rubrics: Physical Assessment

Instruction: Check appropriate level of competence.

With little Somewhat Confident,

No confidence,
confidence, confident, organized and
disorganized,
somewhat organized and with complete
shows no
organized, with sufficient comprehension
comprehension
Procedure of the steps
shows little comprehension of the steps.
comprehension of the steps
of the steps
1 pt. 2 pts. 3 pts. 4 pts.
1. Perform hand washing.

2. Gather all equipment

needed.
 Weighing scale
 Gloves
 Tape
 Tongue blades
 Percussion hammer
 Otoscope
 Tuning fork
 Tape measure
 Snellen chart
 Ophthalmoscope
 Water-soluble pads
 Water soluble lubricant
 Tissue
 Cotton-tipped applicator

3. Identify client and explain the

procedure.

4. Instruct the client to void

before doing the physical
examination.

5. Ensure the privacy of the

client.

6. Assist the patient to undress

and put in a gown.

7. Measure the patient’s height

and weight and take the
vital sign.
 With little Somewhat Confident,
No confidence,
confidence, confident, organized and
disorganized,
somewhat organized and with complete
shows no
organized, with sufficient comprehension
comprehension
Procedure of the steps
shows little comprehension of the steps.
comprehension of the steps
of the steps
1 pt. 2 pts. 3 pts. 4 pts.
8. Observe the client’s:
 General appearance
 Skin color and obvious
lesions
 Dress, grooming and
personal hygiene
 Posture
 Gait
 Motor activity
 Mood and effect
9. Note body and breathe odor
in relation to activity level.
10. Observe for sign of distress,
posture and facial
expression
11. Asses the appropriateness
of client’s response,
relevance and organization
of thought.
12. Listen for quality, quantity
and organization of speech.
13. Assist the client in assuming
a position appropriate for
examination. Drape the
client according to the area
of examination.
14. Conduct the physical
examination starting from
head and ending with the
toe.
15. CRANIAL NERVE
ASSESSMENT

CN I- OLFACTORY NERVE
 Place the client in a
comfortable sitting
position.
 Ask the client to clear
his nose to remove any
mucus. Then ask patient
to inhale/exhale thru the
other, assuring it’s
unobstructed.
 Screen for problems w/
sense of smell using
alcohol pad. Ask patient
to close eyes & present
alcohol pad slowly up
towards the nostril being
tested (checking each
separately).
 No confidence, With little Somewhat Confident,
disorganized, confidence, confident, organized and
shows no somewhat organized and with complete
comprehension organized, with sufficient comprehension
Procedure of the steps shows little comprehension of the steps.
comprehension of the steps
of the steps

1 pt. 2 pts. 3 pts. 4 pts.

 Present patient with a
variety of smelling aids
(onion, coffee, flowers,
etc.), in order to detect
malfunctioning of CN 1

CN II- OPTIC NERVE

 Using hand held card
(held @ 14 inches) or
Snellen wall chart,
assess each eye
separately. Allow patient
to wear glasses. Direct
patient to read aloud line
with smallest lettering
that they’re able to see.
Assess visual fields.
Face patient, roughly 1-
2 ft apart, noses @
same level. Close your
R eye, while patient
closes their L. Keep
other eyes open & look
directly at one another.
Move your L arm out &
away, keeping it ~
equidistant from the 2 of
you. A raised index
finger should be just
outside your field of
vision. Wiggle finger and
bring it in towards your
noses. You should both
be able to detect it @
same time.
 Assess near vision; view
the retina and the optic
disc of the eye with an
ophthalmoscope.

CN III- OCULOMOTOR
NERVE, CN IV- TROCHLEAR
NERVE, CN VI- ABDUCENS
 Inspect the margins of
the eyes.
 Assess extra ocular
movements - Patient
doesn’t move head,
following your finger w/
their eyes as you trace
out letter “H”.
Alternatively, direct them
 No confidence, With little Somewhat Confident,
disorganized, confidence, confident, organized and
shows no somewhat organized and with complete
comprehension organized, with sufficient comprehension
Procedure of the steps shows little comprehension of the steps.
comprehension of the steps
of the steps

1 pt. 2 pts. 3 pts. 4 pts.

to follow finger with their

eyes as you trace large
rectangle
 Test for the six cardinal
points of gaze.
 Assess pupillary
response to light and
accommodation in both
eyes.

CN V- TRIGEMINAL NERVE
 Ask the client to look
upward, lightly touch the
lateral sclera to elicit
blink reflex.
 Ask the client to close
his eyes. Touch the
forehead lightly with
cotton to test light
sensation in three areas
(ophthalmic, maxillary,
mandibular)
 Test deep sensation by
touching the forehead
with a pin or paper clip.

CN VII- FACIAL NERVE

 Observe facial
symmetry.
 Ask the client to smile,
frown, wrinkle the
forehead, puff cheeks,
show teeth, purse lips,
raise eyebrows and
close eyes tightly.
 Ask the client to identify
different tastes by
placing different food
granules (e.g, salt,
coffee, sugar) on the tip
and sides of the tongue.

CN VIII- AUDITORY or
ACOUSTIC NERVE
 Crude test hearing – rub
fingers next to the client’s
ears one at a time,
whisper words then ask
client to repeat them.
 Assess the client’s ability
to hear the vibrations of
 With little Somewhat Confident,
No confidence,
confidence, confident, organized and
disorganized,
somewhat organized and with complete
shows no
organized, with sufficient comprehension
comprehension
Procedure shows little comprehension of the steps.
of the steps
comprehension of the steps
of the steps

1 pt. 2 pts. 3 pts. 4 pts.

the tuning fork. Strike a

512 Hz tuning fork and
place it just beside the
ear and ask client to raise
his hand once he cannot
hear the vibrations
anymore, time the
procedure then repeat in
the other ear.
 Perform the Webber Test
– strike the tuning fork
and place it in the midline
of the skull (frontal area),
ask client to raise his
hand once he cannot
hear the vibrations
anymore.
Perform the Rinne Test
– strike the tuning fork
and place it on the
client’s mastoid bone,
ask client to raise hand
one he cannot hear the
vibrations anymore, then
move the tuning fork
near the client’s ear and
ask to raise his hand if
the vibrations cannot be
heard anymore. Time
both procedures (bone
and air conduction).
Repeat in the other ear.

CN IX-
GLOSSOPHARYNGEAL
NERVE
 Ask the client to open
his mouth and check the
uvula if it is midline. Ask
client to stick out his
tongue and say “Ahhh”.
Use a tongue depressor
if the uvula cannot be
viewed.
 Ask the client to move
his tongue form side to
side, up and down.
 Ask the client to identify
the taste applied on the
posterior part of his
tongue.
 With little Somewhat Confident,
No confidence,
confidence, confident, organized and
disorganized,
somewhat organized and with complete
shows no
organized, with sufficient comprehension
comprehension
Procedure shows little comprehension of the steps.
of the steps
comprehension of the steps
of the steps

1 pt. 2 pts. 3 pts. 4 pts.

CN X - VAGUS NERVE
 Assess the client’s
speech for hoarseness.
 Provoke the gag reflex
(CNs IX and X)

CN XII – HYPOGLOSSAL
NERVE
 Ask the client to
protrude his tongue,
move it to each side
against resistance from
the tongue depressor,
then put it back into his
mouth.
 Assess the tone and
strength of all muscle
groups.

CN XI- ACCESORY NERVE

 Ask the client to raise
his shoulders against
resistance to assess the
trapezius muscle.
Repeat with the other
side.

 Ask the client to turn his

head against resistance,
first to the right then and
to the left.

GRADING SYSTEM REMARKS

95% - 100% Excellent 80% - 84% Satisfactory DRP – Dropped
90% – 94% Superior 75% - 79% Passing INC – Incomplete
85% - 89% Very 74% and below Failed F =- Failed
Satisfactory

Score: _________/__________ x 50 + 50 = ___________

COMMENTS:
__________________________________________________________________________________

________________________
Signature over Printed Name

Evaluated by:

________________________
Clinical Instructor