INTRODUCTION:
❑ Hello my name is _____ and I’ll be your student nurse today! I am going to wash my hands, put on gloves and provide privacy.
Is it okay if I conduct a physical assessment?
GENERAL:
❑ Orientation: Can you state your name and DOB? Do you know what the date is, where you are and why you are here? Patient is
A&Ox4.
❑ Are you in any pain today? Patient appears calm with no signs of distress or anxiety. As I go through each body system, I will
also be assessing the skin which is intact, clean, dry and appropriate for ethnicity.
HEAD & NECK:
❑ Palpating the scalp, there are no lumps, lesions or drainage. Hair is evenly distributed.
❑ The face and ears are symmetrical with no drainage from the eyes, nose, mouth or ears.
❑ Can you open your mouth? The patients mouth has moist, pink oral mucosa and good dentation and the nose is patent.
❑ Please look forward for me, I am going to check the pa eyes- pupils are round and reactive to light light. Keep your head still, and
use your eyes to follow my pen. Eyes also accommodate. The optic, oculomotor, trochlear and abducens cranial nerves are intact.
❑ The neck is symmetrical with no swelling. Palpating the carotid pulses one at a time- they are present 2+ bilaterally.
CHEST:
❑ Assessing the chest, there is equal movement, I will listen to each lung sound for an
inhalation and exhalation. Anterior- 1,2,3,4,5,6,7,8. Posterior- 1,2,3,4,5,6,7,8. Lungs are
clear, breathing is unlabored.
❑ To assess the heart, I will listen to the Aortic, Pulmonic, Erbs point, Tricuspid and Mitral.
This is also the point of maximum impulse and the apical pulse. S1 & S2 are present and
heartrate is regular.
ABDOMEN:
❑ Inspecting the abdomen, it is rounded, nondistended & symmetrical.
❑ Now I will listen to each quadrant for 2-5 minutes, RLQ, RUQ, LUQ, LLQ. Bowel
sounds are present.
❑ I will palpate the abdomen lightly, let me know if you feel any pain. Palpating deeper,
patient does not report any discomfort, so there is no tenderness. Abdomen feels
symmetrical and absent of masses.
❑ When was your last bowel movement? Are you having any constipation, diarrhea, nausea
or vomiting?
❑ Are you having any pain or difficulty urinating, urgency or foul smelling urine?
UPPER EXTREMETIES:
❑ Assessing the upper extremities, the skin turgor has no tenting.
❑ The brachial reflex is 2+.
❑ The radial pulse is present, 2+, equal bilaterally.
❑ The capillary refill is less then 3 seconds, the patient has good circulation.
❑ I am going to assess your motor strength as apart of my neuro assessment, can you squeeze my fingers? Push against my hands,
pull against my hands. Upper body strength is equal bilaterally.
LOWER EXTREMETIES:
❑ Assessing the lower extremities, the patellar reflex is 2+.
❑ The pedal pulse is present, 2+, equal bilaterally.
❑ I am going to assess your motor strength as a part of my neuro assessment, can you push against my hands, and pull against my
hands? Lower body strength is equal bilaterally.
CONCLUSION:
❑ Skin is intact with no lesions, edema or drainage.
❑ Once my assessment is complete, I will put the bed in the lowest position, rails up.
❑ Do you need anything before I leave? I will be back in an hour, here is your call light if you need anything before then
❑ I will take off my gloves and wash my hands.
❑ Hello my name is _____ and I’ll be your student nurse today! I am going to wash my hands, put on gloves and provide privacy.
Is it okay if I conduct a physical assessment?
GENERAL:
❑ Orientation: Can you state your name and DOB? Do you know what the date is, where you are and why you are here? Patient is
A&Ox4.
❑ Are you in any pain today? Patient appears calm with no signs of distress or anxiety. As I go through each body system, I will
also be assessing the skin which is intact, clean, dry and appropriate for ethnicity.
HEAD & NECK:
❑ Palpating the scalp, there are no lumps, lesions or drainage. Hair is evenly distributed.
❑ The face and ears are symmetrical with no drainage from the eyes, nose, mouth or ears.
❑ Can you open your mouth? The patients mouth has moist, pink oral mucosa and good dentation and the nose is patent.
❑ Please look forward for me, I am going to check the pa eyes- pupils are round and reactive to light light. Keep your head still, and
use your eyes to follow my pen. Eyes also accommodate. The optic, oculomotor, trochlear and abducens cranial nerves are intact.
❑ The neck is symmetrical with no swelling. Palpating the carotid pulses one at a time- they are present 2+ bilaterally.
CHEST:
❑ Assessing the chest, there is equal movement, I will listen to each lung sound for an
inhalation and exhalation. Anterior- 1,2,3,4,5,6,7,8. Posterior- 1,2,3,4,5,6,7,8. Lungs are
clear, breathing is unlabored.
❑ To assess the heart, I will listen to the Aortic, Pulmonic, Erbs point, Tricuspid and Mitral.
This is also the point of maximum impulse and the apical pulse. S1 & S2 are present and
heartrate is regular.
ABDOMEN:
❑ Inspecting the abdomen, it is rounded, nondistended & symmetrical.
❑ Now I will listen to each quadrant for 2-5 minutes, RLQ, RUQ, LUQ, LLQ. Bowel
sounds are present.
❑ I will palpate the abdomen lightly, let me know if you feel any pain. Palpating deeper,
patient does not report any discomfort, so there is no tenderness. Abdomen feels
symmetrical and absent of masses.
❑ When was your last bowel movement? Are you having any constipation, diarrhea, nausea
or vomiting?
❑ Are you having any pain or difficulty urinating, urgency or foul smelling urine?
UPPER EXTREMETIES:
❑ Assessing the upper extremities, the skin turgor has no tenting.
❑ The brachial reflex is 2+.
❑ The radial pulse is present, 2+, equal bilaterally.
❑ The capillary refill is less then 3 seconds, the patient has good circulation.
❑ I am going to assess your motor strength as apart of my neuro assessment, can you squeeze my fingers? Push against my hands,
pull against my hands. Upper body strength is equal bilaterally.
LOWER EXTREMETIES:
❑ Assessing the lower extremities, the patellar reflex is 2+.
❑ The pedal pulse is present, 2+, equal bilaterally.
❑ I am going to assess your motor strength as a part of my neuro assessment, can you push against my hands, and pull against my
hands? Lower body strength is equal bilaterally.
CONCLUSION:
❑ Skin is intact with no lesions, edema or drainage.
❑ Once my assessment is complete, I will put the bed in the lowest position, rails up.
❑ Do you need anything before I leave? I will be back in an hour, here is your call light if you need anything before then
❑ I will take off my gloves and wash my hands.
