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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
Posture
Overall hygiene and grooming
Any apparent signs of distress
Dress
Behavior
Level of consciousness
Mood and affect/ Facial expressions (appropriate for situation)
Cognition
Orientation (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 & color
Structure - type of lesion (macule, papule, nodule etc.)
Anatomical Distribution
Hydration – skin turgor (immediate recoil, tenting)
Temperature & Moisture
Inspection and palpation of the hair
Color & condition
Quantity, distribution, & texture
Inspection and palpation of the fingernails
Color of nail bed
Firmness, texture, ridging, irregularities
Clubbing:
Palpate for firm nail matrix
Estimate 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 & tenderness
Face (includes eyes, ears, nose, mouth, and neck)
Symmetry
Discoloration
Lesions
Drainage
Distention
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 Data
Inspect chest wall
Color, Configuration (symmetry) and Lesions
Movement
Respiratory rate, depth, and effort

Auscultate systematically for quality of lung sounds


Assessment 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 Data
HEART
Inspection
Pulsations, lifts, heaves
JVD with chest at 35-45 degree angle
Auscultation
Rhythm assessment of S1 and S2 (Regular/Irregular)
Assess all auscultatory sites: APETM
Count Apical Heart Rate

PERIPHERAL VASCULAR SYSTEM


Palpation of Peripheral Pulses
Radial
Femoral
Posterior Tibial
Dorsalis Pedis
Skin color – extremities (upper and lower)
Capillary refill after blanching (secs)
Fingers/toes
Presence 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 Data
Inspection
Contour
Lesions
Scars
Distention
Pulsations
Hernia (while patient lifts head)
Auscultation (all quadrants)
Bowel sounds
Palpation
Light palpation
Tension of abdominal wall (soft, firm, hard)
Tenderness
Masses
Deep palpation
Tenderness
Masses
Enlarged organs
Percussion
CVA 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 Data
Muscle strength
Check each muscle group against resistance
Compare right with left:
Upper extremities
Triceps
Biceps
Adduction arms
Abduction arms
Wrists – flexion, extension
Lower extremities
Quadriceps
Hamstrings
Abduction knees
Adduction knees
Plantar flexion feet
Dorsiflexion 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 Data
Mental Status Examination
Appearance (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 system
Spinothalamic tract
Light touch
Pain and temperature (only if negative result to light touch)
Posterior column tract
Vibration
Kinesthesia (position sense)
Stereognosis
Graphesthesia
Two-point discrimination
Motor function
Hand grips
Foot pushes
Deep tendon reflexes (Grade)
Biceps C5-C6
Triceps C7-C8
Brachioradialis C5-C6
Quadriceps L2-L4
Achilles L5-S1

Cerebellar Functions
Balance
Gait
Gross motor coordination – heel to toe walking
Romberg
Rapid 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)
Skin
Color (pink, cyanotic, jaundice, dusky, pale)
Hydration – skin turgor
Temp. and Moisture (warm/cool, dry/clammy)
Lesions (describes morphology, size, color, pattern of
Arrangement, and distribution)

Head and Neck


Inspection of skull, face (eyes, ears, nose, mouth, , and neck)
Include oral mucous membranes (moist/dry)
Assess for drainage, lesions, distention, discoloration, and symmetry
Lungs
Performs inspection before auscultation
Assess 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 order
Heart
Identify auscultatory sites:
Aortic – 2nd right ICS
Pulmonic – 2nd left ICS
Tricuspic – Left 5th ICS sternal border or midsternal line
Mitral – 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 Vascular
Palpates for pulses together:
Radial, Femoral, Posterior tibial, Pedal

Capillary refill (secs)


**Assess for edema (depresses medial malleolus
or pretibial area for 5 seconds)
Abdomen
Inspect for contour,lesions,distention
Ausculate all 4 quadrants for bowel sounds
Light palpation all quadrants (bend knees before palpation)
** (begins at RLQ and proceeds clockwise)
Musculoskeletal
ROM and Motor strength against resistance:
Upper extremities (arms only – biceps, triceps)
Lower extremities (legs only – quadriceps)
Functional Assessment
Assess 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 light
Motor - 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.)