Iar Lastern Un|vers|ty

Inst|tute of Nurs|ng


C||n|ca| erformance Lva|uat|on Check||st

Comprehens|ve hys|ca| Assessment
name________________________________________ Score__________
SecLlon/ Croup_______________________ name of lnsLlLuLlon___________________

ect|ve @ls cllnlcal ceckllsL ls formulaLed Lo measure Le sklll knowledge and aLLlLude of Le
sLudenLnurses as demonsLraLed by ls/er cllnlcal compeLence lncludlng undersLandlng and appllcaLlon
of LeoreLlcal prlnclples Lo pracLlce

uirections lease raLe Le sLudenL's performance accordlng Lo Le followlng compeLencles

Legend C,L1LN1 (letfotmooce ls effectlve tbotooqb ooJ pteclse)
3A1IIAC1 (letfotmooce ls osoolly effectlve tbotooqb ooJ pteclse bot oot olwoys)
ACCL1A8LL (letfotmooce oeeJs lmptovemeot ptoqtess ls slow to joJqe sotlsfoctotlly)
LIICILN1 (letfotmooce oeeJs lmptovemeot tosk petfotmooce oot Jooe ptopetly fot mojotlty
of tbe tlme)
L UNACCL1A8LL (Jos oot oble to petfotm ptoceJote)
l@lA 4 3 2 1 0 ,AS
ILNALI1 1AI1 AN ILINAL L (S)


1 onducLs lm/erself ln LacLful pollLe and courLeous manner
2 ulsplays proper groomlng and wears compleLe unlform
3 8eaves approprlaLely Lowards Leacer classmaLes cllenL
4 AccepLs consLrucLlve crlLlclsms
3 eporLs on Llme and aLLends Lo acLlvlLles puncLually
@@AL
II ILL LI,ANCL (9S)


PkP4k41lON
1 CaLer all equlpmenL needed for a eadLoLo e exam
2 erform proper and yglene
3 repare Le cllenL by explalnlng waL you wlll be dolng
PkOcuuk
6enero/ 5urvey
4 bserve appearance
3 Assess vlLal slgns
6 @ake body measuremenL
,enLal SLaLus xamlnaLlon
7 bserve level of consclousness (L%
bserve posLure and body movemenLs
9 bserve speec
10 bserve mood feellngs and expresslon
11 Ask Le cllenL Lo empLy bladder and cange lnLo gown Ask Le
cllenL Lo slL ln Le examlnaLlon Lable

k|n
12 noLe any dlsLlncLlve odor
13 lnspecL/palpaLe for any skln breakdown/leslons prlmary
secondary or vascular leslons noLe slze sape locaLlon
dlsLrlbuLlon and conflguraLlon

14 alpaLe LexLure (roug or smooL% of Le skln uslng palmar
surface of Lree mlddle flngers

13 alpaLe LemperaLure (cool warm oL% and molsLure (dry
sweaLy olly% of skln uslng dorsal slde of and

16 Assess for skln Lurgor by plnclng up Le skln
17 Assess for edema presslng Lumbs over feeL or ankles
ead and Iace
1 lnspecL and palpaLe ead
noLe conslsLency slze sape and conflguraLlon

19 lnspecL and palpaLe alr noLe amounL dlsLrlbuLlon alr color
LexLure olllness and presence of paraslLes

20 bserve face for symmeLry feaLures expresslons condlLlon of
Le skln

21 Pave Le cllenL smlle frown sow LeeL blow ouL ceeks ralse
eyebrows and LlgLly close eyes (n vll%

22 @esL sensaLlons of foreead ceeks and cln (n v%
23 alpaLe Lemporomadlbular [olnL or range of moLlon swelllng
Lenderness or creplLaLlon by placlng lndex flnger over Le fronL
of eac and asklng Le cllenL Lo open mouL

Lyes
24 Assess vlsual funcLlon
a ulsLanL vlsual acqulLy (wlL Snellen carL normal aculLy ls
20/20 wlL or wlLouL correcLlve lenses%

23 lnspecL eyellds and eyelases (wldL and poslLlon of palpebral
flssures ablllLy Lo close eyellds ln comparlson wlL eyeballs
color swelllng leslons or dlscarge%

26 lnspecL poslLlonlng of Le eyeballs (allgnmenL ln sockeLs
proLrudlng or sunken%

27 lnspecL bulbar con[uncLlva and sclera (clarlLy color and LexLure%
2 lnspecL palpebral con[uncLlve (everslon of upper eyellds usually
performed only wlL complalnLs of eye paln or sensaLlon of
someLlng ln eye%

29 lnspecL lacrlmal apparaLus over Le lacrlmal glads (laLeral aspecL
of Le eyelld% and Le puncLa (medlal aspecL of Le lower eyelld%
bserve for swelllng redness or dralnage

30 lnspecL Le cornea and lens by slnlng a llgL Lo deLermlne
Lransparency
31 lnspecL Le lrls and pupll for sape and color of Le lrls and slze
and sape of Le pupll

32 @esL for paplllary reacLlon
33 @esL accommodaLlon of puplls by slfLlng gaze from far Lo near
Lars
34 lnspecL aurlcle Lragus and lobule
33 alpaLe aurlcle and masLold process for Lenderness
36 lnspecL exLernal audlLory canal noLe dlscarge (amounL and
color% and swelllng

37 erform wlsper LesL by avlng Le cllenL place a flnger on Le
Lragus of one ear Wlsper a Lwosyllable word 1 Lo 2 feeL belnd
Le cllenL epeaL on Le oLer ear

3 erform Weber LesL by uslng a Lunlng fork placed on Le cenLer
of Le ead or foreead and asklng weLer Le cllenL ears Le
sound beLLer on one ear or Le same on boL ear

39 erform lnne LesL by uslng Le Lunlng fork placlng Le base on
Le cllenL's masLold process Wen Le cllenL no longer ears Le
sound noLe Le Llme lnLerval and move lL ln fronL of Le exLernal
ear Wen Le cllenL no longer ears a sound noLe Le Llme
lnLerval

40 erform Le omberg LesL Lo evaluaLe equlllbrlum WlL feeL
LogeLer and arms aL Le slde close eyes for 20 seconds bserve
for swaylng

Nose and |nuses
41 lnspecL exLernal nose
42 alpaLe exLernal nose for Lenderness or swelllng
43 lnspecL lnLernal nose for color swelllng exudaLes bleedlng
ulcers perforaLed sepLum or polyps

44 eck paLency of alrflow Lroug nosLrlls
43 cclude eac nosLrll and ask cllenL Lo smell for (eg soap coffee
vanllla eLc% (n l%

46 @ranslllumlnaLe maxlllary slnuses
,outh and 1hroat
47 uL on gloves
4 noLe any dlsLlncLlve odors
49 lnspecL and palpaLe llps buccal mucosa gums and Longue for
color varlaLlons (pallor redness wlLe paLces bluls color%
molsLure Llssue conslsLency or leslons (lnduraLlon rougness
veslcles crusLs plaques nodules ulcers cracklng paLces
bleedlng opllk's spoLs cancer sores% SLensen's and WarLon's
ducLs

30 lnspecL LeeL for number sape color and occluslon
31 bserve uvula
32 Assess for gag reflex (n x%
33 lnspecL Lonslls for color and conslsLency gradlng scales (1+ 2+
3+ 4+%

34 Assess Longue sLrengL (n lx and x%
33 eck LasLe sensaLlon (n vll and lx%
neck
36 lnspecL neck noLe poslLlon symmeLry and presence of lumps
and masses

37 lnspecL movemenL of Lyrold and crlcold carLllage and Lyrold
gland by avlng Le cllenL swallow a small slp of waLer

3 lnspecL neck range of moLlon (,% by avlng Le cllenL Lurn
cln Lo rlgL and lefL soulder Louc ear Lo soulder Louc cln
Lo cesL and llfL cln Lo celllng

39 alpaLe Lracea by placlng flnger ln Le sLernal noLc feellng
eac slde and palpaLlng Le Lraceal rlngs

60 alpaLe Lyrold gland
61 alpaLe lymp nodes for slze/sape dellmlnaLlon moblllLy
conslsLency and Lenderness
a reaurlcular nodes (fronL of ears%
b osLaurlcular nodes (belnd Le ears%
c cclplLal nodes (posLerlor base of skull%
d @onslllar nodes (angle of Le mandlble on Le anLerlor edge of
Le sLernocleldomasLold muscle%
e Submandlbular nodes (medlal border of Le mandlble% don'L
confuse wlL Le lobulaLed submandlbular gland%
f SubmenLal nodes (a few cenLlmeLers belnd Le Llp of Le
mandlble% use one and
g Superflcal cervlcal nodes (superflclal Lo Le sLernomasLold
muscle%
osLerlor cervlcal nodes (posLerlor Lo Le sLernocleldomasLold
and anLerlor Le Lrapezlus ln Le posLerlor Lrlangle%
l Supraclavlcular nodes (ook flngers over clavlcle and feel
deeply beLween Le clavlcles and sLernomasLold muscles%

62 lnspecL Le [ugular velns for dlsLenLlon by placlng cllenL ln a seml
folwer's poslLlon wlL Le ead supporLed on a small plllow
(noLe roceed ln assesslng Le !ugular veln ressure lf !ugular
veln ulsLenslon ls presenL%

63 AusculLaLe caroLld arLerles Lo deLermlne presence of brulL by
asklng cllenL Lo Lurn ead sldeward and placlng Le bell of Le
sLeLoscope over caroLld arLery and ask Le cllenL Lo old breaL
for a momenL so breaL sound do noL conceal vascular sounds
uo Lls on boL sldes of Le neck

64 alpaLe caroLld arLerles wlL exLreme precauLlon by placlng Le
pads of Le lndex and mlddle flngers medlal Lo Le
sLernocleldomasLlod muscle on Le neck noLe conLour and
ampllLude of pulse elasLlclLy of Le arLery and Lrllls

Arms ands and I|ngers
63 lnspecL upper exLremlLles bllaLerally for slze color presence of
edema venous paLLernlng

66 @esL soulder srug and ablllLy Lo Lurn ead agalnsL reslsLance
(n xl splnal%
67 @esL , of soulders
6 alpaLe flngers ands and arms for LemperaLure uslng Le dorsal
surface of flngers

69 ueLermlne caplllary reflll Llme
70 erform Allen's LesL by occludlng Le radlal and ulnar arLerles and
observlng for palm pallor @en release Le ulnar arLery and
waLc for color Lo reLurn Lo and uo Lls ln boL arms

71 @esL , of wrlsL
72 @esL for arpal @unnel Syndrome erfom alen's @esL by asklng
Le cllenL Lo place Le back of Le ands agalnsL eac oLer wlle
flexlng Le wrlsL 90 degrees downwards and old for 60 seconds
noLe Llngllng numbness or paln

73 @esL , of flngers
74 use reflex ammer Lo LesL blcep reflex Ask Le cllenL Lo parLlally
bend arm aL elbow wlL palm up lace Lumb over Le Lendon
and sLrlke Lumb wlL Le reflex ammer epeaL on Le oLer
slde

73 Assess bracloradlalls reflexes Ask Le cllenL Lo flex elbow wlL
palm down and and resLlng on Le abdomen or lap @ap Le
Lendon aL Le radlus abouL 2 lnces above Le wrlsL epeaL on
Le oLer slde

76 Assess Lrlcep reflexes Ask Le cllenL Lo ang ls or er arms
freely wlle you supporL lL wlL your nondomlnanL and WlL
Le elbows flexed Lap Le Lendon above Le olecranon process
epeaL on Le oLer slde

77 @esL sensaLlon ln arms ands and flngers Assess llgL Louc
paln and LemperaLure Ask Le cllenL L close boL eyes and Lell
waL Ley feel and were Ley feel lL ,ake sure Lo scaLLer
sLlmull over Le dlsLal and proxlmal parLs of Le upper
exLremlLles

oster|or and Latera| Chest
7 lnspecL for sape and conflguraLlon of Le cesL wall and poslLlon
of scapulae

79 lnspecL cllenL's poslLlonlng noLlng posLure and ablllLy Lo supporL
welgL wlle breaLlng

0 alpaLe for sensaLlon and Lenderness wlL gloved flngers
1 alpaLe fremlLus uslng Le ball or ulnar edge of one and wlle
cllenL says nlneLynlne" Assess for symmeLry and lnLenslLy of
vlbraLlon

2 alpaLe for cesL expanslon lace ands on Le posLerlor cesL
wall wlL your Lumbs aL Le level of @9 or @10 and observe Le
movemenL of your Lumbs as Le cllenL Lakes a deep breaL

3 ercuss for Lone sLarLlng aL Le aplces above Le scapulae and
across Le Lops of boL soulders

4 ercuss lnLercoasLal spaces across and down comprlslng sldes
3 ercuss Lo Le laLeral aspecLs aL Le bases of Le lungs and
compares sldes
6 AusculLaLe breaL sounds (normal bronclal broncoveslcular
and veslcular%

7 AusculLaLe for advenLlLlous sounds (crackles flne or coarse
pleural frlcLlon rub weeze slbllanL or sonorous%

AusculLaLe for volce sounds over Le cesL wall
a 8roncoponyask Le cllenL Lo repeaL Le prase nlneLy
nlne"
b goponyask Le cllenL Lo repeaL leLLer "
c Wlspered pecLorlloquyasks Le cllenL Lo wlsper Le prase
oneLwoLree"

9 AusculLaLe apex and lefL sLerna border of Le earL durlng
exalaLlon

Anter|or Chest
90 lnspecL cesL for sape and conflguraLlon Lo deLermlne Le raLlo
of anLeroposLerlor dlameLer Lo Lransverse dlameLer

91 lnspecL for poslLlon of sLernum from anLerlor and laLeral
vlewpolnLs

92 lnspecL for quallLy and paLLern of resplraLlon noLlng breaLlng
caracLerlsLlcs raLe ryLm and depL

93 alpaLe surface caracLerlsLlcs suc as leslons or masses uslng
flngers of gloved and

94 alpaLe fremlLus wlle Le cllenL says nlneLynlne"
93 AusculLaLe for breaL sounds advenLlLlous sounds and volce
sounds

Iema|e 8reasts
96 8llaLerally lnspecL Le breasL for slze symmeLry and conLour or
sape wlle Le cllenLs ls ln slLLlng poslLlon

97 8llaLerally lnspecL Le skln of Le breasL for locallzed
dlscoloraLlons or yperplgmenLaLlon reLracLlon or dlmpllng
locallzed ypervascular areas swelllng or edema

9 alpaLe breasLs for masses Lenderness and any dlscarge from
Le nlpples

99 alpaLe Le areola and Le nlpples for masses and dlscarge
ompress eac nlpple Lo deLermlne presence of any dlscarge
*lf dlscarge ls presenL mllk Le radlus Lo ldenLlfy Le dlscarge
produclng lobe noLe dlscarge for amounL color conslsLency
and odor

100alpaLe Le axlllary subclavlcular and supraclavlcular lymp
nodes by placlng Le cllenL ln a slLLlng poslLlon wlL Le arms
abducLed and supporLed on Le nurse's forearm

101@eac Le cllenL Le Lecnlque of breasL selfexamlnaLlon
,a|e 8reasts
102lnspecL breasL Llssue
103alpaLe breasL Llssue and axlllae
eart
104lnspecL for vlslble pulsaLlons (noLe lf aplcal or oLer%
103AusculLaLeearL sounds for raLe and ryLm (aplcal and radlal
pulse raLe deflclL S
1
and S
2
%

106AusculLaLe for exLra earL sounds (cllcks rubs% and murmurs
107AusculLaLe wlL Le cllenL ln Le lefL laLeral poslLlon and wlL Le
cllenL slLLlng up leanlng forward and exallng

Adomen
10 roperly drape Le cllenL exposlng only Le abdomen
109lnspecL Le skln noLlng color vascularlLy sLrlae scars and
leslons

110lnspecL umblllcus noLlng color locaLlon and conLour
111lnspecL conLour of Le abdomen
112lnspecL abdomlnal movemenL noLlng resplraLory movemenL
aorLlc pulsaLlon and/or perlsLalLlc waves

113AusculLaLe for bowel sounds noLlng lnLenslLy plLc and
frequency

114AusculLaLe vascular sounds and frlcLlon rubs
113ercuss abdomen for Lone
116ercuss Le llver
117ercuss Le spleen
11erform blunL percusslon on Le llver and Le kldneys
119erform llgL palpaLlon noLlng Lenderness or masses ln all
quadranLs

120erform deep palpaLlon noLlng Lenderness or masses ln all
quadranLs

121alpaLe Le umblllcus and Le surroundlng areas for swelllngs
bulges or masses

122alpaLe Le aorLa
123alpaLe Le llver noLlng conslsLency and Lenderness
124alpaLe Le spleen noLlng conslsLency and Lenderness
123alpaLe Le kldneys
126alpaLe Le urlnary bladder
127erform Le LesL for slfLlng dullness
12erform fluld wave LesL
129erform Le balloLLemenL LesL
130erform LesL for appendlclLls
a ebound Lenderness
b ovslng's slgn
c eferred rebound Lenderness
d soas slgn
e bLuraLor slgn
d PypersenslLlvlLy LesL

Legs
131lnspecL bllaLerally for skln color (cllenL ln suplne poslLlon%
132lnspecL bllaLerally for alr dlsLrlbuLlon
133lnspecL for leslons or ulcers (noLe weLer marglns are smooL
and even locaLlon suc as pressure polnLs slze depL dralnage
and odor%

134lnspecL for edema unllaLeral or bllaLeral (lf calves are
asymmeLrlc measure calf clrcumference%
*lf Le cllenL as edema deLermlne weLer lf lL's plLLlng or non
plLLlng lf Le cllenL as plLLlng edema raLe on 1+ Lo 4+ scales

133Assess caplllary reflll
136alpaLe skln LemperaLure (cool warm oL% use dorsal surface of
Le ands

137alpaLe Le superflclal lngulnal lymp nodes wlle keeplng Le
genlLals draped lf deLecLed noLe slze moblllLy or Lenderness

13alpaLe and ausculLaLe femoral pulses over arLery LlsLen for
brulLs

139alpaLe popllLeal dorsalls pedls and posLerlor Llblal pulses
140Ask Le cllenL Lo slL on Le edge of Le examlnaLlon Lable so LaL
ls legs ang freely

141@esL sensaLlons Assess llgL Louc paln and LemperaLure Ask Le
cllenL L close boL eyes and Lell waL Ley feel and were Ley feel
lL ,ake sure Lo scaLLer sLlmull over Le dlsLal and proxlmal parLs
of Le lower exLremlLles

142LocaLe paLellar Lendon dlrecLly below Le paLella
143uellver a blow wlL a percusslon ammer dlrecLly Lo Le Lendon
bserve Le normal exLenslon or klcklng ouL of Le leg as Le
quadrlceps muscle conLracLs

144WlL Le cllenL ln Le same poslLlon as for Le paLellar reflex
sllgLly dorslflex Le cllenL's ankle by supporLlng Le fooL llgLly ln
Le and

143uellver a blow wlL Le percusslon ammer dlrecLly Lo Le
Acllles Lendon [usL above Le eel bserve and feel normal
plaLar flexlon (downward [erk% of Le fooL

146Assess for lanLar (8ablnskl's% eflex by uslng a moderaLely sarp
ob[ecL suc as andle of Le percusslon ammer key or dull end
of Le pln or appllcaLor sLlck SLroke laLeral border of Le cllenL's
fooL sLarLlng aL Le eel conLlnulng Lo Le ball of Le fooL
proceedlng across Le ball of Le fooL Lo Le blg Loe noLe for
response

147@esL , of knees
14lnspecL and palpaLe ankles for poslLlon allgnmenL sape skln
Lenderness LemperaLure swelllng or nodules

149@esL , of ankle and Loes
,uscu|oske|eta|
130Ask Le cllenL Lo assume a sLandlng poslLlon
131bserve for splnal curvaLure and ceck for scollosls
132@esL , of Le Loraclc and lumbar splne Ask Le cllenL Lo bend
forward and Louc Le Loes bserve for symmeLry of Le
soulders scapula and lps

133SlL belnd Le cllenL sLablllzed Le cllenLs pelvls wlL your ands
and ask Le cllenL Lo bend sldeways bend backward Loward you
(yperexLenslon% and LwlsL Le soulders one way Len Le oLer

(roLaLlon%
134bserve galL for base welgLbearlng sLablllLy feeL poslLlon
sLrlde arm swlng and posLure

133uocumenL flndlngs ln Le cllenL record
@@AL
CAulnC AcLual Score/@oLal number of lLems *100 llnal Crade


uaLe ____________________
SlgnaLure of SLudenL over rlnLed name _____________________________

uaLe ____________________
SlgnaLure of llnlcal lnsLrucLor over rlnLed name _____________________












*volootloo tool fot neoltb Assessmeot fot level 1 lot osteto uolvetslty A20102011
kefeteoces
Weber ! elly ! Sprengel A (2007% lob Mooool to Accompooy neoltb Assessmeot lo Notsloq 1bltJ Jltloo
Weber ! elly ! (2007% neoltb Assessmeot lo Notsloq 1bltJ Jltloo
ozler 8 rb C 8erman A Snyder S (2004% looJomeotols of Notsloq cbeckllst 5eveotb Jltloo