Practice  -- PHYSICAL ASSESSMENT

Name: __________________________________ Partner_______________________________

Using inspection, palpation, and auscultation, practice physical assessment according to lecture notes/ textbook.  Document findings on a separate sheet of paper and submit at the conclusion of lab today.

Physical assessment begins with a general survey of your client.  Begin your assessments from the first moment you see the client.  Your observations should provide data to guide your further assessments.

Using your notes as a guide to proper documentation, assess your partner relative to :

  • Level of Consciousness
  • Age (apparent vs. actual)
  • State of Health (appears well developed, well nourished)
  • Nutritional status
  • Personal hygiene
  • Signs of Distress
  • Facial expression (mood, affect)
  • Mental status:  (orientation: cognitive abilities)
  • Height, weight, vital signs

Integument:

     Inspect for color, temperature, turgor, lesions and rashes. inspect hair and nails: practice blanch (capillary refill) test.

Head/face:

     Inspect; note any deviations.

Eyes:

     Inspect eyelids for position and lesion; conjunctiva for color; cornea for opacity or scratch.  Assess pupils, noting size, equality, shape, reaction to light and accommodation (PERRLA).  Extraocular movements.

Ears:

     Inspect external ear; test auditory acuity.

Nose:

     Inspect nares; note drainage, patency; CN-I (olfactory)

Oropharynx:

     Inspect lips; teeth, gums, oral mucosa, tongue.  Inspect pharynx –tonsils, uvula.

 Neck:

     Evaluate ROM; inspect for JVD; palpate for nodes, carotid pulse.

Thorax:

  • Inspect thorax
    • Respiratory rate/pattern. 
    • Note AP/ transverse diameters.
    • costal angle
  • Palpate for pain, lesions, and respiratory excursion.
  • Auscultation: systematic listening side to side, top to bottom 
    • Identify areas for bronchial, bronchovesicular and vesicular sounds.    
    • Auscultate all lung fields; identify lobe of lungs– report findings.

Cardiovascular:

  • Identify aortic, pulmonic, tricuspid and mitral areas (which heart sound is louder?). 
  • Identify the PMI.  Obtain the apical rate.
  • Auscultate heart sounds; identify S-1, S-2.
  • Palpate peripheral pulses; record on scale 1-4+. 
  • Inspect lower extremities for edema (report on scale of 1-4+) or temperature changes. 
  • Perform Homan’s test.

Abdomen:

  • Inspect shape/size of abdomen; note scars, lesions. 
  • Auscultate bowel sounds in all quadrants.
  • Light palpation, rebound tenderness, palpate bladder

Musculoskeletal:

  • Note posture; gait. 
  • Assess muscle tone and strength.

Neurological:

  • Determine level of consciousness and orientation.
  • Note thought processes, speech, mood and behavior. 
  • Test grips and ability to feel light touch to lower extremities.  

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