ARELLANO UNIVERSITY

COLLEGE OF NURSING
1058 Taft Avenue, Pasay City

EVALUATION TOOL

PHYSICAL ASSESSMENT 2

NAME: _____________________________________________________ DATE: ____________________ SCORE: _____________

SCORE
CRITERIA
4 3 2 1
I. ATTITUDE – 10%
1. Report on time
2. Wears complete prescribed uniform
3. Neat and well-groomed
4. Observes proper decorum
5. Acknowledges criticism/ suggestions cheerfully
6. Shows mastery of the activity
TOTAL = 24
II. KNOWLEDGE – 20%
1. States objectives of the activity
2. Uses appropriate terms
3. States steps of the procedure in correct order
4. Explains rationale of the steps
TOTAL = 16

III. SKILLS COMPETENCY – 70%

A. ASSESSMENT
GENERAL APPEARANCE
1. Performs hand washing before the procedure
2. Preparation of the equipment
a. Stethoscope, skin marker, ballpen, patient’s gown, linen for draping
b. Assembles articles completely, quickly and according to use
c. Maintains safety and asepsis in the use of articles
3. Preparation of the Environment
a. Prepares an assessment room that is quiet, well lighted and well ventilated
B. PLANNING
1. Plans proper positioning of the client
2. Plans for proper draping of the client
C. IMPLEMENTATION
a. Preparation of the Client
1. Greets and identifies client, introduces self
2. Explains the purpose of the activity, what will be done and what instruments will be used.
3. Ask the client to use comfort room before the physical assessment
4. Position the client comfortably during the physical assessment
5. Prepares client properly and avoids unnecessary exposure
b. Concern for Client
1. Handles client gently
2. Relays results to the client
3. Speaks in client’s level of understanding
4. Expresses self readily and appropriately
c. Communication Skills
 1. Uses appropriate terms, grammar is correct
2. Speaks in client’s level of understanding
3. Expresses self readily and appropriately

SCORE
CRITERIA
4 3 2 1
NECK
BODY PART

INSPECTION
a. Observe the patient’s neck, the skin, and symmetry of the neck.
b. Note any scars, visible pulsations, masses, swelling, venous distention, thyroid gland or lymph node
enlargement.
c. Ask the patient to move his neck through the entire range of motion and to shrug his shoulders.
PALPATION
a. Warm the hands
b. Palpate the patient’s neck using the finger pads of both hands.
c. Assess the lymph nodes for size, shape, mobility, consistency, temperature and tenderness,
comparing nodes on one side with those on the other.
AUSCULTATION
a. Warm the stethoscope
b. Using light pressure on the bell of the stethoscope, listen over the carotid arteries. Ask the patient
to hold his breath while you listen to prevent breath sounds from interfering with the sounds of
circulation.
c. Listen for bruits, which signal turbulent blood flow.
d. Auscultate the thyroid area with the bell. Check for a bruit or soft rushing sound
POSTERIOR THORAX and LUNGS
INSPECTION
a. Provide client privacy. Drape the anterior chest if not being examine.
b. Stand at the back of the client
c. Observe for the skin color, moles, scars, hair and distribution
d. Inspect the shape and symmetry of the thorax from posterior and lateral views.
e. Observe the anteroposterior diameter
f. Note symmetry of the scapula
g. Observe intercostals spaces and movements, Inspect spinal alignment for deformities
PALPATION
a. Warm the hands
b. Palpate for temperature and integrity of chest skin
c. Palpate for bulges, tenderness or abnormal movement
d. Palpate for vocal/tactile fremitus.
PERCUSSION
a. Percuss chest wall systematically
b. Place pleximeter flat on body surfaces
c. Strike pleximeter finger with plexor finger
d. Identify percussion notes and determine its character
AUSCULTATION
a. Warn stethoscope with the palms of the hand
b. Auscultate systematically
c. Identify breath sounds and determine its character
HEART
INSPECTION AND PALPATION
a. Locate the valve areas of the heart
b. Inspect and palpate for pulsations on valve areas
c. Inspect and palpate the epigastric area at the base of the sternum for abdominal aortic pulsations
AUSCULTATION
a. Auscultate the heart in all four anatomical sites: aortic, pulmonic, tricuspid, apical (mitral)
b. Count heartbeat in one full minute
BREAST, NIPPLES, AND AREOLA
INSPECTION
a. Inspect the breast for size, symmetry, and contour or shape
 b. Inspect the skin of the breast for dimpling or retraction, hyperpigmentation or localized
discolorations
c. Inspect for localized hyper vascular areas, swelling or edema
d. Inspect the areola for size, shape, symmetry and color
e. Inspect the nipple for size, shape, position, color, discharge and lesions
PALPATION
a. Warm the hands
b. Ask the client to raise the arm of the part to be assessed
c. Palpate the axillary, sub clavicular, and supraclavicular lymph nodes
d. Palpate the breast for masses, tenderness and lumps
e. Palpate the areola and the nipples for masses
f. Compress each nipple using thumb and index finger to determine the presence of any discharge.
Assess any discharge for amount, color, consistency, and odor
ABDOMEN
INSPECTION
a. Ask the client if he needs to void
b. Place the client in a dorsal recumbent position
c. Drape the upper chest and legs. Expose the abdomen from the xiphoid process to the symphysis
pubis.
d. Identify the four (4) quadrants and nine (9) regions of the abdomen
e. Observe for the general appearance: color, skin integrity, contour, symmetry, movement or
pulsations, mole, scars, hair distribution and skin discoloration
f. Observe the location and protrusion of the umbilicus
g. Observe abdominal movements associated with respiration, peristalsis, or aortic pulsations
AUSCULTATION
BOWEL SOUNDS
a. Warm the hands and the diaphragm of the stethoscope
b. Ask the client when was the last time he have eaten
c. Place the flat-disc diaphragm of the stethoscope in each of the four quadrants of the abdomen
d. Count bowel sounds in one full minute
PERCUSSION
a. Percuss abdomen systematically
b. Place prelimeter flat on body surfaces
c. Strike pleximeter finger with plexor finger
d. Identify percussion notes and determine character

SCORE
CRITERIA 1
4 3 2
PALPATION
LIGHT PALPATION
a. Stand on the client’s side
b. Warm the hands
c. Perform light palpation to detect tenderness, the presence of masses or distention, muscle
guarding, outline and position of abdominal organs
d. Palpate all four quadrants
DEEP PALPATION
a. Depress the abdominal wall about 1 ½ to 2 inches. Note masses, structure of the underlying
contents. Check for rebound tenderness in the area
b. Palpate for the liver: place left hand on the posterior thorax at about 11th or 12th rib and applies
upward pressure
c. Place the right hand along the rib cage at about 45 degrees angle
d. While the client exhales, exert a gradual and gentle down ward and forward pressure until 1 ½ to 2
inches
AFTER CARE
1. Arrange articles properly and systematically
2. Throw wastes or used articles in the trash can
EVALUATION
1. ACCURACY IN RECORDING
A. Neat and legible
B. Accurate
C. comprehensive
TOTAL
GRADING SYSTEM: ATTITUDE 10%
KNOWLEDGE 20%
SKILLS 70%

RATE THE STUDENT FROM 1-4 WHERE;

4 – Very Satisfactory exhibits competency independently
3 – Satisfactory exhibits competency with minimal supervision
2 – Fair exhibits competency fairly with close supervision
1 – Needs Improvement did not exhibit competency

FORMULA FOR GETTING THE GRADE PERCETAGE:

ATTITUDE (PERFECT SCORE: 24) Grade Percentage = raw score x 55 + 45 x 10%
Perfect score
KNOWLEDGE (PERFECT SCORE: 16) Grade Percentage = raw score x 55 + 45 x 20%
Perfect score
SKILLS (PERFECT SCORE: 36) Grade Percentage = raw score x 55 + 45 x 70%
Perfect score
FINAL GRADE = ATTITUDE + KNOWLEDGE + SKILLS

REMARKS / SUGGESTIONS:

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Clinical/ Instructor’s Signature over Printed Name & Date Student’s Signature over Printed Name &
Date