PERFORMING A COMPREHENSIVE PHYSICAL ASSESSMENT
Item # Item Description What to Say/Do Example
1. Assemble workable, well-arranged I’m going to gather my equipment and
equipment. assemble a workable environment and
provide privacy.
*2. Wash hands. Don gloves.
*3. Introduces self and identifies the client. Hi, my name is Chloe, and I am your nurse
today. Can I have you please verify your
name and date of birth?
*4. Asks client about allergies (i.e., food, Do you have any allergies?
environmental, medications, latex, iodine,
etc.).
5. Verbally prepare the client for the exam. Today I’ll be performing a comprehensive
physical assessment, I have a lengthy list of
items here that I’m going to run through
with you, is that okay?
6. Observe posture and gait upon entering When the client first entered the room, I
assessment location, including obvious observed their gait and it was steady, no
deformities, and use of assistive devices. obvious deformities, and no use of assistive
device were needed.
*7. General survey of the client: LOC: Can you tell me what day of the
week it is? Do you know where we are?
Appears stated age, LOC, evaluate skin And why you’re here? Client is alert and
color, nutritional status, facial expression, oriented to person, place, time, and
mood/affect, speech (articulation, pattern, situation.
language spoken, and hygiene.
Age: Client appears stated age.
Skin color: Their skin color is appropriate
for complexion.
Nutritional status: Their weight appears
within normal range of height and body
build.
Facial expression: Expressions are
appropriate to the situation.
Mood/affect: Client appears comfortable
and cooperative and interacts pleasantly.
Speech: Articulation is clear and
understandable.
Hygiene: Client appears clean and
groomed appropriately for their age.
8. HEIGHT AND WEIGHT OMITTED. If someone’s vision is 20/70, this means
Only going to ask about the Snellen Chart. that something that should be visible at 70
feet, the person must be at 20 feet to see
it clearly.
I would then check your height and weight.
WHILE STANDING IN FRONT OF CLIENT (CLIENT SITTING)
*9. VITAL SIGNS OMITTED – woohoo! I would then check your vitals starting with
Temperature, Pulse, Respiration, Blood
Pressure and O2 sat.
, PERFORMING A COMPREHENSIVE PHYSICAL ASSESSMENT
*10. Obtain Pain Assessment Do you currently have any pain?
1. Provocative/Palliative P: What provokes it? What makes it feel
2. Quality/Quantity better?
3. Region/Radiation Q: Is it throbbing? Aching? Sharp? Or Dull?
4. Severity R: Where is the pain?
5. Timing/Treatment S: On a scale of 1-10 how severe is the
pain?
T: When did it start? And have you taken
anything for the pain?
11. Obtain pulse oximetry. Check client’s O2 sat using a pulse ox.
12. CN I (olfactory) – Assess client’s sense of CN 1 (olfactory): I’m going to ask you to
16. smell. close your eyes and I’m going to place a
smell under your nose, if you can please
tell me what it is.
13. CN II (optic) – Evaluate client’s visual CN 2 (optic): I’ll be checking your visual
fields. fields. Can you please cover one eye and
let me know when you can see the penlight
by saying ‘now’.
14. CN III (oculomotor), CN IV (trochlear), CN CN 3 (oculomotor), CN 4 (trochlear), &
VI (abducens) – Test. CN 6 (abducens): I’ll be assessing your six
cardinal fields of gaze.
15. CN V (trigeminal) – Evaluate masseter & CN 5 (trigeminal): I’m going to use a
19. temporomandibular joint. cotton tip at 3 points, and you let me know
1. Assess TMJ through palpation. if you can feel them.
2. Assess TMJ through ROM.
Then I’m going to palpate your TMJ and
have you move your jaw side to side and
against resistance.
16. Assess client’s CN VII (facial). CN 7 (facial): Can I have you puff out
12. your cheeks? Raise your eyebrows? And
squint your eyes?
17. CN VIII (vestibulocochlear) – Test client’s CN 8 (vestibulocochlear): I’m going to
15. hearing with whispered voice test (or have you close your eyes and please let
rubbing between two fingers) me know when/if you hear something and
on which ear.
, PERFORMING A COMPREHENSIVE PHYSICAL ASSESSMENT
*18. CN IX (glossopharyngeal), CN X (vagus) – CN 9 (glossopharyngeal) & CN 10
*17. Test gag reflex & swallow. (vagus): I’m going to use a tongue blade
and assess your gag reflex and your
ability to swallow.
19. CN XII (hypoglossal) – Assess tongue CN 12 (hypoglossal): And while I’m here,
18. movement & strength. I’ll also be testing your tongue movement
and strength so if you can just push against
the tongue blade.
20. CN XI (spinal accessory) – Assess strength CN 11 (spinal accessory): I’m going to
of sternocleidomastoid & trapezius apply pressure to your shoulders while you
muscles. shrug to assess strength of your
sternocleidomastoid and trapezius muscles.
Then I will have you rotate your head
against resistance.
21. Inspect symmetry of client’s head/face. I’m looking at the client’s head and face
for symmetry. Client’s head appears
normocephalic (a round symmetric skull
that is appropriately r/t body size).
22. Inspect and palpate client’s scalp and hair. I’m going to palpate you scalp and hair, is
that okay?
There are no lumps, depressions, or
abnormal protrusions and hair is
distributed evenly.
23. Examine client’s external eye (lids, lashes, I’ll be assessing your external eye. The skin
sclera, conjunctiva). is intact without redness, swelling,
discharge, or lesions. Eyelashes are
distributed evenly.
I’m going to ask you to look up while I pull
down your lower lid with my thumbs to
check your palpebral conjunctiva.
Next, I’m going to ask you to look down
while I pull up to expose your upper lid to
check your bulbar conjunctiva. I’m
inspecting for any redness or swelling.
Conjunctiva is pink, sclera is white, and the
eyeball looks moist and glossy.
24. Palpate client’s lacrimal gland and duct. I’m palpating the lacrimal gland and duct;
do you feel any tenderness?
25. Evaluate client’s pupils for PERRLA and I’ll be checking your pupils, so I just need
size: you to look straight ahead, and I’ll be
1. Evaluate client’s left eye. shining a light on your left and right eye
2. Evaluate client’s right eye. noting direct light reflex and consensual
3. Evaluate client’s pupillary light reflex. Pupils are equal, round, and
accommodation. reactive to light.
I’ll also be checking accommodation so if
you can just follow the pen light.
Item # Item Description What to Say/Do Example
1. Assemble workable, well-arranged I’m going to gather my equipment and
equipment. assemble a workable environment and
provide privacy.
*2. Wash hands. Don gloves.
*3. Introduces self and identifies the client. Hi, my name is Chloe, and I am your nurse
today. Can I have you please verify your
name and date of birth?
*4. Asks client about allergies (i.e., food, Do you have any allergies?
environmental, medications, latex, iodine,
etc.).
5. Verbally prepare the client for the exam. Today I’ll be performing a comprehensive
physical assessment, I have a lengthy list of
items here that I’m going to run through
with you, is that okay?
6. Observe posture and gait upon entering When the client first entered the room, I
assessment location, including obvious observed their gait and it was steady, no
deformities, and use of assistive devices. obvious deformities, and no use of assistive
device were needed.
*7. General survey of the client: LOC: Can you tell me what day of the
week it is? Do you know where we are?
Appears stated age, LOC, evaluate skin And why you’re here? Client is alert and
color, nutritional status, facial expression, oriented to person, place, time, and
mood/affect, speech (articulation, pattern, situation.
language spoken, and hygiene.
Age: Client appears stated age.
Skin color: Their skin color is appropriate
for complexion.
Nutritional status: Their weight appears
within normal range of height and body
build.
Facial expression: Expressions are
appropriate to the situation.
Mood/affect: Client appears comfortable
and cooperative and interacts pleasantly.
Speech: Articulation is clear and
understandable.
Hygiene: Client appears clean and
groomed appropriately for their age.
8. HEIGHT AND WEIGHT OMITTED. If someone’s vision is 20/70, this means
Only going to ask about the Snellen Chart. that something that should be visible at 70
feet, the person must be at 20 feet to see
it clearly.
I would then check your height and weight.
WHILE STANDING IN FRONT OF CLIENT (CLIENT SITTING)
*9. VITAL SIGNS OMITTED – woohoo! I would then check your vitals starting with
Temperature, Pulse, Respiration, Blood
Pressure and O2 sat.
, PERFORMING A COMPREHENSIVE PHYSICAL ASSESSMENT
*10. Obtain Pain Assessment Do you currently have any pain?
1. Provocative/Palliative P: What provokes it? What makes it feel
2. Quality/Quantity better?
3. Region/Radiation Q: Is it throbbing? Aching? Sharp? Or Dull?
4. Severity R: Where is the pain?
5. Timing/Treatment S: On a scale of 1-10 how severe is the
pain?
T: When did it start? And have you taken
anything for the pain?
11. Obtain pulse oximetry. Check client’s O2 sat using a pulse ox.
12. CN I (olfactory) – Assess client’s sense of CN 1 (olfactory): I’m going to ask you to
16. smell. close your eyes and I’m going to place a
smell under your nose, if you can please
tell me what it is.
13. CN II (optic) – Evaluate client’s visual CN 2 (optic): I’ll be checking your visual
fields. fields. Can you please cover one eye and
let me know when you can see the penlight
by saying ‘now’.
14. CN III (oculomotor), CN IV (trochlear), CN CN 3 (oculomotor), CN 4 (trochlear), &
VI (abducens) – Test. CN 6 (abducens): I’ll be assessing your six
cardinal fields of gaze.
15. CN V (trigeminal) – Evaluate masseter & CN 5 (trigeminal): I’m going to use a
19. temporomandibular joint. cotton tip at 3 points, and you let me know
1. Assess TMJ through palpation. if you can feel them.
2. Assess TMJ through ROM.
Then I’m going to palpate your TMJ and
have you move your jaw side to side and
against resistance.
16. Assess client’s CN VII (facial). CN 7 (facial): Can I have you puff out
12. your cheeks? Raise your eyebrows? And
squint your eyes?
17. CN VIII (vestibulocochlear) – Test client’s CN 8 (vestibulocochlear): I’m going to
15. hearing with whispered voice test (or have you close your eyes and please let
rubbing between two fingers) me know when/if you hear something and
on which ear.
, PERFORMING A COMPREHENSIVE PHYSICAL ASSESSMENT
*18. CN IX (glossopharyngeal), CN X (vagus) – CN 9 (glossopharyngeal) & CN 10
*17. Test gag reflex & swallow. (vagus): I’m going to use a tongue blade
and assess your gag reflex and your
ability to swallow.
19. CN XII (hypoglossal) – Assess tongue CN 12 (hypoglossal): And while I’m here,
18. movement & strength. I’ll also be testing your tongue movement
and strength so if you can just push against
the tongue blade.
20. CN XI (spinal accessory) – Assess strength CN 11 (spinal accessory): I’m going to
of sternocleidomastoid & trapezius apply pressure to your shoulders while you
muscles. shrug to assess strength of your
sternocleidomastoid and trapezius muscles.
Then I will have you rotate your head
against resistance.
21. Inspect symmetry of client’s head/face. I’m looking at the client’s head and face
for symmetry. Client’s head appears
normocephalic (a round symmetric skull
that is appropriately r/t body size).
22. Inspect and palpate client’s scalp and hair. I’m going to palpate you scalp and hair, is
that okay?
There are no lumps, depressions, or
abnormal protrusions and hair is
distributed evenly.
23. Examine client’s external eye (lids, lashes, I’ll be assessing your external eye. The skin
sclera, conjunctiva). is intact without redness, swelling,
discharge, or lesions. Eyelashes are
distributed evenly.
I’m going to ask you to look up while I pull
down your lower lid with my thumbs to
check your palpebral conjunctiva.
Next, I’m going to ask you to look down
while I pull up to expose your upper lid to
check your bulbar conjunctiva. I’m
inspecting for any redness or swelling.
Conjunctiva is pink, sclera is white, and the
eyeball looks moist and glossy.
24. Palpate client’s lacrimal gland and duct. I’m palpating the lacrimal gland and duct;
do you feel any tenderness?
25. Evaluate client’s pupils for PERRLA and I’ll be checking your pupils, so I just need
size: you to look straight ahead, and I’ll be
1. Evaluate client’s left eye. shining a light on your left and right eye
2. Evaluate client’s right eye. noting direct light reflex and consensual
3. Evaluate client’s pupillary light reflex. Pupils are equal, round, and
accommodation. reactive to light.
I’ll also be checking accommodation so if
you can just follow the pen light.
