Physical Assessment Check-Off

Question 1

Introduction (4)

Answer 1

1. Wash your hands
2. Identify Self
3. Identify patient using 2 patient identifiers
4. Note call light in reach (At end)

Question 2

General Survey (4)

Answer 2

Address at least 4 of the following:
1. Mental status (level of consciousness x4)
2. Pain
3. Physical appearance: Nutritional status
4. Hygiene and grooming (body odor, hair, nails)
5. Behavior: Response to introduction
6. Facial expression: symmetry and appropriateness
7. Speech: clarity, fluency, quality, and appropriateness
8. Body posture and position, relaxation, or comfort

Question 3

Skin (6)

Answer 3

1. Temperature
2. Color
3. Moisture
4. Assess skin turgor
5. Assess for lesions/wounds/incision scars
6. Assess for IV, drainage, tubes (note location)

Question 4

Head/Neck (3)

Answer 4

1. Bruits
   - have patient hold breath
   - should not hear swishing
2. JVD (jugular vein dissention using bell of stethoscope)
   - trachea should be midline
3. Palpate carotid artery (one side at a time)

Question 5

Eyes (8)

Answer 5

1. PERRLA (pupils equal round reactive to light and accommodation) (5)
   - check each eye for constriction
   - check each eye for opposite eye constriction
   - distance for accommodation
2. Vision (does patient wear glasses or contacts)
3. Drainage
4. Sclera Color

Question 6

Ears (2)

Answer 6

1. Hearing (conversation and whisper)
   - do whisper test
2. Device (does patient wear hearing aids)

Question 7

Nose (2)

Answer 7

1. Drainage
2. Smell

Question 8

Mouth/throat (4)

Answer 8

1. Moisture (lips and gums)
2. Gums and Teeth
3. Dentures
4. Swallowing

Question 9

Respiratory System (4)

Answer 9

1. Respiratory Effort
2. Oxygen therapy
3. Auscultate breath sounds anterior, posterior, and midaxillary
4. Assess for coughing; if productive, assess sputum

Question 10

Cardiovascular System (11)

Answer 10

1. (5) Auscultate five key landmarks: aortic valve (2nd intercostal space right side), pulmonic valve (2nd intercostal space left side), Erb’s point (third intercostal space, tricuspid (4th intercostal space),
2. (3) Assess peripheral pulses: radial, dorsalis pedis, posterior tibial bilaterally
3. (2) Assess for capillary refill (fingers and toes)
4. Assess peripheral edema

Question 11

Abdomen (5)

Answer 11

1. Inspect (for contour, skin color, pulsations)
2. Auscultate bowel sounds
3. Palpate
4. Assess time of most recent bowel movement and or flatus
5. Assess drains, tubes, dressings, when indicated
   - must be in the above order!!!!

Question 12

Genitourinary (2)

Answer 12

1. Assess urine output: voiding frequency and amount, or catheter drainage amount (does the patient have any discomfort, burning, or odor when voiding)
2. Assess color and clarity of urine (should be clear and pale yellow)

Question 13

Activity (8)

Answer 13

1. Assess gait and coordination of movements
2. Assess ability to move self to sit and standing positions
3. Assess for joint deformities/abnormalities
4. Assess for presence of and use of assistive devices
5. Assess for risk of falls (oxygen tubes, LOC, age, and medications)
6. Assess the environment for mobility hazards
7. Upper and lower strength (squeeze fingers, push and pull bilaterally and dorsiflex and plantarflex feet)
8. Upper and lower ROM

Question 14

Documentation (1)

Answer 14

1. Document findings