First City Providential College

Brgy. Narra, Francisco Homes, City of San Jose del Monte, Bulacan
Tel (044) 815-6814 Fax (044) 815-7137 email: firstcityprovidentialcollege@yahoo.com
www.firstcity.ph
College of Nursing/School of Midwifery

Name of Student: ______________________________________________________ Score: _______________ Date: __________

Year/Section/Group: _______________________

PHYSICAL ASSESSMENT
PERFORMANCE POINTS 4 3 2 1 REMARKS

I. KNOWLEDGE
1. State the goal of Physical Assessment
To obtain baseline data of the client’s functional abilities
To assess the general health status of the client
To obtain data that will enable the nurse to establish nursing diagnoses and
plan client care
2. Explain the rationale of each suggested action
3. Enumerate the equipment to be used:
Weighing Scale
Height Chart
Pen Light
Neurologic Hammer / Reflex Hammer
Sphygmomanometer and cuff
Stethoscope
Thermometer
Tuning Fork
Tongue Depressor
Cotton Applicator
Examination Gloves
II. SKILLS
1. Identify the client.
2. Explain the procedure and discuss how she or he can cooperate.
3. Perform hand hygiene.
4. Provide privacy.
5. Position the client comfortably allowing for easy access to the body part
being assessed.
General Survey
6. Describe body built.
7. Measure height and weight and determine BMI
8. Describe posture and gait (Observe client while standing, sitting and
walking)
9. Describe over-all hygiene and grooming (Relate these to the persons
activities prior to the assessments.)
10. Identify signs of distress in posture or facial expression.
11. Note obvious signs of health or illness.
12. Assess the client’s attitude.
13. Describe client’s affect / mood.
14. Assess appropriateness of client’s responses.
15. Describe quantity of speech (amount and pace)
16. Listen for the relevance and organization of thoughts.
Integumentary
Skin
17. Inspect for skin color uniformity, presence of edema.
18. Inspect for lesions according to locations, distribution, color, configuration,
size, shape, type or structure
19. Palpate skin moisture and temperature
20. Note for skin turgor by lifting and pinching the skin
Hair
21. Inspect the evenness of growth over the scalp.
22. Inspect hair for volume. (Thickness and Thinness)
23. Inspect for texture and oiliness over the scalp
24. Note for presence of infection and infestations
25. Inspect amount of body hair.
Nails
26. Inspect fingernail plate shape to determine its curvature and angle
27. Inspect and palpate fingernail and toenail texture
28. Inspect tissues surrounding nails
29. Perform blanch test of capillary refill
Head
Skull and Face
30. Inspect the skull for the size, shape and symmetry.
31. Palpate for modules, masses and depressions.
32. Inspect the facial features, symmetry of facial movements.
33. Inspect the eyes for edema and hollowness.
Eyes
Eyelashes
34. Inspect for the evenness of hair distribution and direction of curl
Eyebrows
35. Inspect for the evenness of hair distribution and alignment / symmetry, skin
quality and movement.
Eye lids
36. Inspect for the surface characteristics, position in relation to the cornea,
ability to blink and frequency of blinking
37. Inspect the bulbar conjunctiva (lying over the sclera) for color, texture and
presence of lesions.
38. Inspect the palpebral conjunctiva (lining the eye lids) for color, texture and
presence of lesions by everting the eyelids.
39. Evert the upper eyelids, if a problem is suspected.
40. Inspect and palpate the lacrimal gland
41. Inspect and palpate lacrimal sac and nasolacrimal duct.
Cornea
42. Inspect the cornea for the clarity and texture.
43. Perform corneal sensitivity test.
44. Inspect the anterior chamber for transparency and depth.
Pupils
45. Inspect pupils for the color, shape symmetry of size.
46. Assess each pupil for light reaction and accommodation.
Sclera
47. Inspect for the color and clarity
Iris
48. Inspect for the color and shape
Extraocular Muscles
49. Assess six ocular movements to determine alignment and coordination.
50. Perform eye cover test.
Visual Acuity
51. Test for near and distant vision.
Visual Fields
52. Assess Peripheral visual fields.
Ears
Auricles
53. Inspect for color, symmetry of size and position.
54. Palpate for the texture, elasticity and areas of tenderness.
Ear Canal
55. Inspect cerumen, skin lesions, pus and blood
Hearing Acuity Tests
56. Assess client’s response to normal voice tones
57. Assess client’s response to whispered voice.
58. Perform the watch tick test.
59. Perform the Weber’s Test to assess bone conduction by placing the activated
tuning fork on the client’s skull.
60. Perform the Rinne’s Test to compare air conduction to bone conduction by
placing the ringing tuning fork at the mastoid process until no sound is heard
and then place the prongs of the tuning fork in front of the client’s ear canal.
Nose
External Nose
61. Inspect external nose for any deviations in shape, size or color and flaring or
discharge from the nares.
62. Inspect the nasal cavities for redness, swelling, growths and discharge using
penlight.
 63. Inspect the nasal septum between the nasal chambers noting its position.
64. Test patency of both nasal cavities
65. Palpate for any tenderness, masses and displacements of bone and cartilage.
Sinuses
66. Locate / palpate / identify sinuses and note for any tenderness.
Mouth
Lips and buccal mucosa
67. Inspect for symmetry of contour, color and texture.
68. Inspect and palpate the inner lips and buccal mucosa for color, moisture,
texture and the presence of lesions.
Teeth
69. Inspect for the color, number and condition and presence of dentures.
Gums
70. Inspect for the color and condition.
Tongue / Floor of the Mouth
71. Inspect and palpate surface of the tongue for the position, color, texture,
movement, and base of the tongue
72. Inspect for the texture of the mouth floor and frenulum.
73. Palpate for any nodules, lumps or excoriated areas.
Palates and Uvula
74. Inspect and palpate for the color, shape, texture and presence of bony
prominences.
75. Inspect uvula for position and mobility while examining the palates.
Oropharynx and Tonsils
76. Inspect and palpate oropharynx for color, shape, texture and presence of bony
prominences
77. Inspect size of tonsils, its color, size and presence of discharge
78. Elicit gag reflex
NECK
Neck Muscles
79. Inspect sternocleidomastoid and trapezius muscles of the neck for abnormal
swelling or masses.
80. Observe head movement.
81. Assess muscle strength.
Lymph Nodes
82. Locate / palpate/ identify lymph nodes and note for tenderness and
enlargement.
Trachea
83. Inspect and palpate for placement.
Thyroid Gland
84. Inspect for symmetry and masses.
85. Palpate for smoothness and areas of enlargement, masses and nodules.
THORAX
Posterior Thorax
86. Inspect for the shape, symmetry and compare the diameter of anteroposterior
thorax to transverse diameter
87. Inspect the spinal alignment
88. Palpate for temperature, tenderness and masses.
89. Assess for respiratory excursion.
90. Palpate for vocal fremitus.
91. Percuss the posterior thorax.
92. Auscultate the posterior thorax.
Anterior Thorax
93. Inspect breathing patterns and costal angle formed by the intersection of the
costal margins and the angle at which the ribs enter the spine.
94. Palpate for temperature, tenderness and masses.
95. Assess respiratory excursion.
96. Palpate for tactile fremitus.
97. Percuss the anterior thorax.
98. Auscultate the trachea.
99. Auscultate the anterior thorax.
CARDIOVASCULAR
Simultaneously Inspect and Palpate the Precordium for the presence of abnormal
pulsations, lifts or heaves
100. Aortic and pulmonic areas.
101. Tricuspid area and the apical area.
 102. Epigastric area at the base of the sternum.
103. Auscultate the heart in all four anatomical areas: aortic, pulmonic,
tricuspid and apical (mitral)
Carotid Artery
104. Palpate carotid artery with extreme caution
105. Auscultate the carotid arteries
Jugular Veins
106. Inspect for the jugular vein distension.
Peripheral Pulses
107. Palpate peripheral veins in the arms and legs for presence of
superficial veins and any sign of phlebitis.
Peripheral Veins
108. Inspect for the jugular vein distension.
BREAST AND AXILLAE
109. Inspect the breast for size, symmetry and contour or shape while the
client in sitting position.
110. Inspect the skin of the breast for localized discolorations or
hyperpigmentation retraction or dimpling, swelling or edema.
111. Inspect areola for size, shape, symmetry, color, masses or lesions.
112. Inspect for the nipple size, shape, position, color, discharge and
lesions.
113. Palpate the breast for masses, tenderness and any discharge from the
nipples.
114. Palpate the axillary, subclavicular and supraclavicular lymph nodes.
ABDOMEN
115. Inspect the abdomen for skin integrity.
116. Inspect abdomen for contour and symmetry.
117. Inspect the abdominal movements associated with respirations,
peristalsis or aortic pulsations.
118. Inspect for presence of vascular pattern.
119. Auscultate the abdomen for bowel sounds, vascular sounds and
peritoneal friction rubs.
120. Perform light palpation first then deep palpation in all four quadrants.
121. Palpate for an enlarge liver and spleen.
122. Percuss several areas in each of the four quadrants for presence of
tympany and dullness
MUSCULOSKELETAL
Muscles
123. Inspect muscles for size, presence of contractures, and tremors
124. Palpate muscles at rest to determine tonicity.
125. Palpate muscles while client is active and passive for flaccidity,
spasticity and smoothness of movement.
126. Test Muscle Strength.
Bones
127. Inspect the skeleton for normal structure and deformities.
128. Palpate the bones for edema or tenderness.
Joint
129. Inspect for the location, color and swelling or masses
130. Palpate for any tenderness crepitation and presence of nodules
131. Assess joint Range of Motion (ROM).
Cervical, Thoracic and Lumbar Spine
132. Observe for symmetry, tenderness and presence of pain.
133. Perform ROM of the cervical spine (flexion, hyperextension, lateral
bending and rotation).
134. Perform ROM of the thoracic and lumbar spine (flexion,
hyperextension, lateral bending and rotation).
Shoulders, Arms and Elbows
135. Observe the shoulders and arms for the symmetry, swelling, color
and masses.
136. Perform ROM of the shoulder (Adduction, aduction, external and
internal rotation).
137. Observe for the elbow’s size, shape, deformities, redness or swelling.
138. Palpate for the olecranon process and epicondyles in relaxed and
flexed position.
139. Perform ROM of elbows.
Wrist
 140. Inspect and palpate for size, shape, symmetry, color and swelling.
Then palpate for snuffbox for tenderness ad nodules.
141. Perform ROM of the wrist. (Flexion, hyperextension, radial and ulnar
deviation)
Hands and Fingers
142. Inspect for size, shape, symmetry, color and swelling of hands,
fingers and metacarpophalangeal joint.
143. Palpate for tenderness, swelling of bony prominences, nodules or
crepitus of each interphalangeal joint.
144. Perform ROM of hands and fingers (abduction, adduction, flexion
and hyperextension, thumb away from fingers, thumb touching base of small
finger).
Hips
145. Inspect and palpate for shape, symmetry, stability, tenderness and
crepitus.
146. Perform ROM of the hips (hip flexion with extended knee straight,
hip flexion with knee bent abduction, adduction, internal and external
rotation, hyperextension).
Knees
147. Inspect the knees for the size, shape, symmetry, swelling, deformities
and alignment.
148. Palpate for tenderness, warmth, consistency and nodules.
149. Perform ROM of the knees (flexion, extension, hyperextension, ask
the patient to walk).
Ankles and Feet
150. Perform ROM of the ankles and feet .(dorsiflexion, plantar flexion,
eversion, inversion, abduction, adduction, flexion and extension)
III. ATTITUDE
1. Answers the question politely
2. Shows effort to improve performance
3. Work harmoniously with the clinical instructor and group mates
4. Reports in clean uniform, well-groomed and neat
TOTAL SCORE

_____________________________________________

Clinical Instructor’s Name over Signature