10 minute Physical Assessment

Wash hands introduce self, Pt teaching on performing a head to toe assessment, provide privacy, ID pt, verify allergies GSC check & Orientation check with 4 questions: Person, place, time, event Surveying room: Check oxygen flow and delivery system Check IV sites/ IV drip rate/ solution General Survey of pt: Are they talking? Are they breathing? What is their skin color? What are the surroundings? Head (back head/ears) Inspect Head for lumps, bumps, hair distribution; characteristics Inspect ears for corrosion from nasal cannula or glasses; canals for wax, discharge, drainage Assess outside of ears: hearing aid? Drainage? Obstruction? Did you have to speak louder and slower for pt to understand conversation? What kind of intervention? Demonstrate. Head (eyes) Inspect sclera, eye lids, irises Shine light into pts pupils, PERRLA, consensual, EOM, accommodation Head (nose) Assess nose: Ask pt about patency, drainage, deviated septum? Head (lips) Inspect lips/ mouth for cracked skin, ill fitting dentures, tongue texture, mucous membranes, teeth in good repair? Neck: Inspect neck for JVD (45 degree angle) if Cardiac pt Auscultate Carotid with bell, have pt hold breath if Cardiac pt Palpate chest for crepitus, when does crepitus occur? Arms: Palpate both radial pulses to compare if equal Capillary refills Test Muscle strength of arms, push and pull Chest (lungs) Tell pt to remove gown Inspect chest for symmetrical breaths or accessory muscle use with breathing; Auscultate breath sounds A (6):P (7)areas (under clothes) p. 301,7 Auscultate for entire inspiration and expiration phase While listening to back of lungs: assess pts back buttocks skin. Heart: Palpate carotid OR radial pulse when auscultating Apex of heart, Is there a pulse deficit? How many beats difference? Auscultate heart sounds x 5 areas A, P, E, T, M (bell & diaphragm) Describe sounds of murmur vs. gallop if auscultated Abdomen: Inspect Abdomen for pulsing masses, distended bladder, bruises Auscultate abdomen for bowel sounds x 4 quadrants (light diaphragm pressure) Palpate lower abdomen for distended bladder Legs: Assess both lower legs for hair distribution, skin color, edema Palpate pedal pulses (both of them at same time) check cap refill of toes/ pads, check heel Test muscle strength of pedal pushes and pulls Wash hands, lower bed, rails up, call light within reach Summary statement to pt: Ill be backIll check for your meds

Updated LSF 8/11