PHYSICAL ASSESSMENT DOCUMENTATION GUIDE

Student____________________________ Date ________________

Client/Patient ___________________________Age ________Sex__________

General State of Health

Subjective Data: (Obtain all info under “General State of Health” from Review of Systems page 5 of Jarvis)

Objective Data:Appearance

PostureOverall hygiene and groomingAny apparent signs of distressDress

BehaviorLevel of consciousness Mood and affect/ Facial expressions (appropriate for situation)

CognitionOrientation (person, place, time, and purpose-X4)Speech (clear, garbled, slurred, incomprehensible)Responsiveness (follows directions and responds appropriately)

Documentations: (Include both Subjective and Objective Data in Narrative Form)

PHYSICAL ASSESSMENT DOCUMENTATION GUIDE

Student____________________________ Date ________________

Client/Patient ___________________________Age ________Sex__________

Assessment of the Skin, Hair, and Nails

Subjective Data: (Obtain all info under “Skin”, “Hair”, & “Nails” from Review of Systems page 5 Jarvis)

Objective Data:Inspection and palpation of the skin

Color(pink, cyanotic, jaundiced, erythematous),Pigmentation (even, hyper/hypopigmentation)Lesions (Describe 3)

Description – size & colorStructure - type of lesion (macule, papule, nodule etc.)Anatomical Distribution

Hydration – skin turgor (immediate recoil, tenting)Temperature & Moisture

Inspection and palpation of the hairColor & conditionQuantity, distribution, & texture

Inspection and palpation of the fingernailsColor of nail bedFirmness, texture, ridging, irregularitiesClubbing:

Palpate for firm nail matrixEstimate nail angle

Documentation: (Include both Subjective and Objective Data in Narrative Form)

PHYSICAL ASSESSMENT DOCUMENTATION GUIDE

Student____________________________ Date ________________

Client/Patient ___________________________Age ________Sex__________

Assessment of the Head and Neck

Subjective Data: (Obtain all info under “Head, Eyes, Ears, Nose, Mouth and Neck” from Review of Systems page 5-6 Jarvis)

Objective Data:Inspection and palpation of the head and face

Skull for symmetry & tendernessFace (includes eyes, ears, nose, mouth, and neck)

SymmetryDiscolorationLesionsDrainageDistention

Oral mucous membranes –color, hydration, lesions

Documentation: (Include both Subjective and Objective Data in Narrative Form)

PHYSICAL ASSESSMENT DOCUMENTATION GUIDE

Student____________________________ Date ________________

Client/Patient ___________________________Age ________Sex__________

Assessment of the Chest and Lungs

Subjective Data: (Obtain all info under Respiratory from Review of Systems in Jarvis page 6)

Objective DataInspect chest wall Color, Configuration (symmetry) and LesionsMovement

Respiratory rate, depth, and effort

Auscultate systematically for quality of lung soundsAssessment of lung sounds and location

(Clear, diminished, absent)Identify adventitious sounds if present:

Wheezes (sibilant or sonorous rhonchi)Crackles (fine or course)

Documentation: (Include both Subjective and Objective Data in Narrative Form)

PHYSICAL ASSESSMENT DOCUMENTATION GUIDE

Student____________________________ Date ________________

Client/Patient ___________________________Age ________Sex__________

Assessment of the Heart and Peripheral Vascular System

Subjective Data: (Obtain all info under Cardiovascular, Peripheral Vascular from Review of Systems page 6 Jarvis)

Objective DataHEARTInspection

Pulsations, lifts, heavesJVD with chest at 35-45 degree angle

AuscultationRhythm assessment of S1 and S2 (Regular/Irregular)

Assess all auscultatory sites: APETM Count Apical Heart Rate

PERIPHERAL VASCULAR SYSTEMPalpation of Peripheral Pulses

RadialFemoralPosterior TibialDorsalis Pedis

Skin color – extremities (upper and lower)Capillary refill after blanching (secs)

Fingers/toesPresence of Edema- depress for 5 seconds (grade if pitting)

Documentation: (Include both Subjective and Objective Data in Narrative Form)

PHYSICAL ASSESSMENT DOCUMENTATION GUIDE

Student____________________________ Date ________________

Client/Patient ___________________________Age ________Sex__________

Assessment of the Abdomen

Subjective Data: (Obtain all info under Gastronintestinal, Genitourinary from Review of Systems page 6-7 Jarvis)

Objective DataInspection

ContourLesionsScarsDistentionPulsationsHernia (while patient lifts head)

Auscultation (all quadrants)Bowel sounds

PalpationLight palpation

Tension of abdominal wall (soft, firm, hard)TendernessMasses

Deep palpationTendernessMassesEnlarged organs

PercussionCVA tenderness

Documentation: (Include both Subjective and Objective Data in Narrative Form)

PHYSICAL ASSESSMENT DOCUMENTATION GUIDE

Student____________________________ Date ________________

Client/Patient ___________________________Age ________Sex__________

Assessment of the Musculoskeletal System

Subjective Data: (Obtain info from Review of Systems under Musculoskeletal in Jarvis)

Objective DataMuscle strength

Check each muscle group against resistanceCompare right with left:

Upper extremitiesTricepsBicepsAdduction armsAbduction armsWrists – flexion, extension

Lower extremitiesQuadricepsHamstringsAbduction kneesAdduction kneesPlantar flexion feetDorsiflexion feet

Documentation: (Include both Subjective and Objective Data in Narrative Form)

PHYSICAL ASSESSMENT DOCUMENTATION GUIDE

Student____________________________ Date ________________

Client/Patient ___________________________Age ________Sex__________

Neurological Assessment

Subjective Data: (Obtain info from Review of Systems under Neurological in Jarvis)

Objective DataMental Status ExaminationAppearance (posture, body movement, dress appropriate

for setting, grooming/hygiene)Behavior (level of consciousness, facial expression,

mood and affect)Cognition (orientation x4, responsiveness, speech)Thought Processes (thought content for consistency and logic, perceptions

consistency with reality, any suicidal thought)

Pupillary Reaction (equality, size, shape, reaction to direct and consensual light)

Sensory systemSpinothalamic tract

Light touchPain and temperature (only if negative result to light touch)

Posterior column tractVibrationKinesthesia (position sense)StereognosisGraphesthesiaTwo-point discrimination

Motor functionHand gripsFoot pushes

Deep tendon reflexes (Grade)Biceps C5-C6Triceps C7-C8Brachioradialis C5-C6Quadriceps L2-L4Achilles L5-S1

Cerebellar FunctionsBalance

GaitGross motor coordination – heel to toe walkingRombergRapid Alternating Movements (RAM)

Documentation: (Include both Subjective and Objective Data in Narrative Form)

PHYSICAL ASSESSMENT PRACTICUM

Student____________________________ Date ________________

**Starred ** items are critical elements and must be passed by the student.

Technique Organization Clear Description (5) (5) Instructions(2) Accurate (4)

General Survey:Appearance (posture, grooming, hygiene,

apparent signs of distress, dress)Behavior (attitude, mood and affect, facial expressions)Cognition (mental status, speech, level of orientation)

SkinColor (pink, cyanotic, jaundice, dusky, pale)Hydration – skin turgorTemp. and Moisture (warm/cool, dry/clammy)Lesions (describes morphology, size, color, pattern of

Arrangement, and distribution)

Head and NeckInspection of skull, face (eyes, ears, nose, mouth, , and neck)Include oral mucous membranes (moist/dry)

Assess for drainage, lesions, distention, discoloration, and symmetryLungsPerforms inspection before auscultationAssess respiratory effort and rate

Assess for symmetry of chest wall movement (chest expansion symmetrical)Auscultate for breath sounds (anterior or posterior chest)

in a systematic orderHeart

Identify auscultatory sites:Aortic – 2nd right ICSPulmonic – 2nd left ICSTricuspic – Left 5th ICS sternal border or midsternal lineMitral – left 5th ICS midclavicular line

**Auscultate S1 and S2 - assess rhythm (S1 S2 Reg./irreg.)assess for extra heart sounds & murmurs

Identify PMI (left 5th ICS midclavicular line)Count Apical heart rate (BPM)

Technique Organization Clear Description(5) (5) Instruction (2) Accurate (4)

Peripheral VascularPalpates for pulses together:Radial, Femoral, Posterior tibial, Pedal

Capillary refill (secs) **Assess for edema (depresses medial malleolus or pretibial area for 5 seconds)

AbdomenInspect for contour,lesions,distentionAusculate all 4 quadrants for bowel soundsLight palpation all quadrants (bend knees before palpation)** (begins at RLQ and proceeds clockwise)

MusculoskeletalROM and Motor strength against resistance:

Upper extremities (arms only – biceps, triceps)Lower extremities (legs only – quadriceps)

Functional AssessmentAssess pt’s ability to get up out of chair or bed (with or without

Assistance: minimal or maximal assist)Neurological

Pupils - equal, round, reactive to direct and consensual lightMotor - Assess hand grips and foot pushes bilaterally**Sensory – light touch (use cotton ball to forehead, cheek,

chin, upper extremities, and lower extremities)**Balance – Romberg Test (assesses for swaying

within 20 seconds). **Critical Element: stands behind or beside patient in case patient falls.Gait – normal gait (steady/unsteady/shuffled)

TOTAL SCORE: _____/144 /45 /45 /18 /36

COMMENTS:

CRITICAL ELEMENTS (** STARRED ITEMS) __________SATISFACTORY __________UNSATISFACTORY (STUDENT MUST TAKE NRSG 251-ADULT P.A.)