Guide to Physical Assessment Mastery Demonstration

You must address each section of physical assessment.

** indicates critical assessment elements that must be present and accurate.

Introductions

ID band check and introduction of self and procedure.

General Survey

(give some information to show your instructor the you have the concept of general survey

• Age, state of health, nutritional status, personal hygiene,
• **signs of distress, facial expression/mood, level of  consciousness and orientation x3.

Vital Signs

Verbalize TPR B/P

Head

• Size, symmetry, and deformity
• Scalp: lumps, lesions
• Hair: texture, hygiene, fullness / loss
• Face: color, temperature, moisture

Eyes

• Eyelids – position, lesion, color of conjunctiva
• **Pupils: PERRLA --- perform and explain

Nose / Sinus

Nose shape, patency, discharge

Sinus – palpate for tenderness

Ears

• acuity
• External -- **lesions, drainage, auditory acuity

Oropharynx

• Lips color, lesions
• **Oral mucosa color, lesions
• Teeth present, dentition, gums intact
• Tongue position, texture, color
• **Tonsils presence, appearance, size, exudates
• Gag reflex present

Neck

ROM;  **palpate for enlarged nodes

**JVD – describe, explain significance

Thorax

• Inspection -- **A/P ratio, deformities, respiratory excursion
• **describe respiratory pattern
• **describe type of breath sounds and area where they are normally found
  • Bronchial – harsh, heard over trachea and sternum
  • Bronchovesicular – medium pitch, heard close to sternum and between scapulae
  • Vesicular – soft, low, heard in periphery
• **Auscultation of all lung fields (5 lobes).  Side to side and front to back, not over bone
• **Describe adventitious sounds
•    Crackles – fine, high-pitched crackling sound
•    Rhonchi – low-pitched, gurgling moaning sound

Heart

**Distinguish areas of assessment

• Aortic – 2nd ICS right of sternum
• Pulmonic – 2nd ICS left of sternum
• Erbs – 3^rd ICS left of sternum
• Tricuspid – 5^th ICS left of sternum
• Mitral – 5^th ICS @ midclavicular line

**Auscultate and define heart sounds in these areas:

• Aortic/Pulmonic: hear S2 “dub”   louder than S1         
• Tricuspid/Mitral:  hear S1 “lub” , louder than S2
• Mitral area: PMI, Apical pulse

Peripheral Vascular

**Pulses: temporal, carotid, brachial, radial, femoral, popliteal, dorsalis pedis, posterior tibial – check bilaterally for equality

Edema – accumulation of fluid in tissues, assess and report on scale of 1+ to 4+

Abdomen

• **Inspection for contour (distention) scars, lesions, rashes, bruising, wounds, ostomies
• Auscultation:  **Listen in 4 quadrants
• **Describe bowel sounds as gurgling/tinkling, occurring every 5-20 X min.  Absence of sound (must listen for 5 minutes to be absolute).
• Palpation:  **Palpate for tenderness, abdominal or bladder distention using palmar surface of 3 fingers in light, dipping motion

Extremities

• Should be symmetrically equal.
• **Skin:  Color, moisture, turgor, temperature, integrity.
• **Fingers:  Capillary refill, nail color.
• ROM: Able to flex, extend, abduct, adduct. Rotate internally and externally.
• **Legs:  Homan’s sign – perform manipulation - (positive finding: sharp calf pain on dorsiflexion).