Introduction

“Hello, My name is … . I’m a nursing student from Broward College. “

Wash hands, put on gloves.
First I’m going to do eyeball assessment of the room and safety of the patient.
“Could you tell me your full name? Date of birth?”
“Do you know where you are? And what year is it?”
Patient is alert, active, oriented to person, place, time.
“I’m going to be doing a brief physical assessment today. Before we begin, would you like to use
the restroom/ bedpan?”
*if the answer is “yes”, assist the patient, perform hand hygiene, put on new pair of gloves.
Raise the bed to a working level.

Head

We are going to start with the head.

Hair is clean, the is no lumps, moles, lacerations, pediculosis, or tenderness. Head is
normocephalic. Hear distribution is even, no alopecia.

Change gloves.

Nose

Assess the nares with pen light

“Have you had surgery on your nose or fractures?”
No deviated septum, polyps, or drainage.
(Occlude one nostril at a time)
“Take a breath. Do you have any difficulty breathing?”

“Please, close your eyes. Tell me what do you smell?”

(bring something from breakfast tray)
Cranial nerve 1 (Olfactory) is intact.

Eyes

Sclera is white, conjunctiva is pink and moist, pupil size is 3/4mm”

“Do you wear glasses or contacts?”
“Can you read my badge? What about this sign? (point to a distant sign)”
Cranial nerve 2 (Optic) is intact.
I’m going to perform a Pupil Reflex test.
(shine the light in patient’s eyes)
(shine the light with hand placed on the bridge of patient’s nose) Reaction is brisk and
consensual.
“Please, look at my pen and then look at the sign on the wall and then at my pen again.”
Pupils are equal, round, reactive to light and accommodation.

I’m going to check 6 cardinal fields of gaze/ extraoccular eye movements.

“please, follow my pen with your eyes only, without moving your head”
Cranial nerve 3 (Occulomotor), cranial nerve 6 (Abducens), cranial nerve 4 (Trochlea) are intact.

Testing for convergence.

(move pen light to the nose and back, assessing cross eyes)
Bilateral symmetrical movement of both eyes.

Face

Face is symmetrical. Skin color is even, no unusual moles. Hair distribution of eyelashes and
eyebrows is even and symmetrical.
(Palpate forehead, sinuses)
“Do you have any tenderness or discomfort?”
There are no signs of edema on the face.

(Palpate Temporal mandibular joint)

“Could you cling your jaw? Do you have any pain during mastication?”
“Please, close your eyes and tell me when you feel me touching your face”
Cranial nerve 5 (Trigeminal) is intact.
“Could you puff your chicks, smile, raise your eyebrows”
Cranial nerve 7 (Facial) is intact.

Ears

Ears are symmetrical. No excess cerumen, drainage, bleeding.

(palpate back of the ears)
“Do you feel any tenderness?”
“Do you have any difficulty hearing or wear hearing aids?”
“I’m going to perform whisper test. Please, repeat what I say” (whisper in both ears)
Cranial nerve 8 (Acoustic) is intact.

Mouth

“please, open your mouth”

Mucosa is pink and moist. No excess cavities or signs of infection. No lesions, bleeding, or gum
inflammation.
“please say Ahh …. And swallow”
Cranial nerve 9 (Glossopharyngeal) and Cranial nerve 10 (Vagus) are intact.
Uvula is midline.

“Please stick out your tongue and move it from side to side. Touch the roof of your mouth with
the tip of your tongue”
Frenulum and cranial nerve 12 (hypoglossal) are intact.

Shoulders

“do you have pain or decreased movement in shoulders?”

(place hands on the shoulders)
“Could you shrug your shoulders?”
(place hand on one side of patients head and then the other)
“Please push your face against my hand”
Cranial nerve 11 (Spinal Accessory) is intact.

Neck

Neck is symmetrical, no lesions, or unusual moles.

(palpate for nodules)
No swelling.
Trachea is midline.

“Please look straight ahead”

Negative for JVD –Jugular vein distention.

(palpate carotid arteries one at a time)

Pulse is regular, even +2 bilaterally.

(auscultate with the bell of the stethoscope)

negative for bruit.

Thorax

I’m going to inspect the chest. Skin color is even. No lesions or moles.
(palpate) No lumps or edema.
(pinch the skin- skin Turgor)
No tenting.
Heart

(Auscultate with diaphragm)

Aortic- right of sternal border, 2nd intercostal space. S2 is louder.
Pulmonic- left of sternal border, 2nd intercostal space. S2 is louder.
Erb’s point- left of sternal border, 3nd intercostal space. S1 and S2 are equal.
Tricuspid- left of sternal border, 4nd intercostal space. S1 is louder.
Mitral- left of sternal border, 5nd intercostal space, midclavicular. S1 is louder.
This is a point of maximum impulse and it is where apical pulse is auscultated for 1 minute.

Lungs

Anterior:
(auscultate with diaphragm)
“please take deep breath in with your nose and out with your mouth”
trachea- bronchial sounds, louder on expiration
above clavicles- vesicular sounds, louder on inspiration
2nd, 3rd,4th intercostal space (compare side to side)- broncho-vesicular sound, equal on
inspiration and expiration.

Women: midaxilla 4th, 5th intercostal space – vesicular

Men: can continue to 5th intercostal to hear vesicular

Posterior:
Beginning from T3 near spine – broncho-vesicular
The periphery – vesicular (auscultate in six different areas)

(place hands on either side of patients back with thumbs close together)
“please take a deep breath”
Lungs expand equally bilaterally

“please sit up”

(place one hand on the chest and another hand on the back)
AP (antiposterior) diameter is less than transverse.

Abdomen

“ Do you have any trouble voiding? When was your last bowel movement?”
“When was your last period”
“Do you perform routine breast exam/ testicular exam?”

(lower the head of the bed)

No lesions, lumps, scars, pulsations, abdominal distention.
“have you had any problems with appetite, pain, nasea?”
(auscultate abdominal aorta with the bell)
Abdominal aorta is absent for bruit

(auscultate with the diaphragm 4 quadrants)

I will listen to all quadrants for 1 min, I will expect to hear 5 to 35 sounds
*if I don’t hear any sounds I will listen to that quadrant for 5 minutes

(palpate abdomen)
“do you feel any discomfort?”

Upper extremities

Skin color is even, no moles, lumps. Even hair distribution.

(palpate) Skin is warm and dry. No edema

I’m going to check CMS – circulation, mobility, sensation

(check brachial, radial pulses)
Pulse is easily palpable, +2 , equal bilaterally

(check capillary refill)

Brisk capillary refill, less than 2 seconds

“please wiggle you fingers”

“close your eyes and tell when you feel my touch” (touch different areas of hands and arms)

I’m going to assess range of motion

“please raise your arm…” (show different ROM)

“squeeze my hands”
No neurological deficit, full range of motion / Atrophy, neurological deficit

Lower extremities

Skin color is even, no moles, lumps. Even hair distribution.

(palpate) Skin is warm and dry. No edema or varicose veins.

I’m going to check CMS – circulation, mobility, sensation

(check femoral, popliteal, posterior tibialis, dorsalis pedis)
Pulse is easily palpable, +2 , equal bilaterally
(check capillary refill)
Brisk capillary refill, less than 2 seconds

“please wiggle you toes”

“close your eyes and tell when you feel my touch” (touch different the leg)

I’m going to assess range of motion

“please raise your leg…” (show different ROM)

“push your feet down like you are pressing on gas pedal”
No neurological deficit / Atrophy, neurological deficit

I’m going to check for Homan’s sign

(lift the leg) “point your foot towards your face? Do you feel any sharp pain in your calf?”

Back

(palpate along the spine)

“Do you feel any discomfort or pain?”
Normal curvature of the spine

(check perianal area)

No lesions, hemorrhoids, or bleeding

Lower the bed

Make sure 3 side rails are up
Take of gloves, perform hand hygiene