Physical Assessment
1. Walk in and sanitize your hands while introducing yourself.
2. Let patient know you are going to be their nurse today.
3. Verify patients name, date of birth, and if any allergies?
4. Inform patient it’s time for their assessment which involves putting your stethoscope on
them and you will be asking then to do a few tasks for you, “is that okay?”
5. Put gloves on for assessment. (“how are you feeling today, any pain”)
6. Ask patient to see both hands and explain you are checking for capillary refill.
a. Nails: Healthy fingernails and toenails should generally be a pink color - with the
healthy nail plate being pink, and the nail being white in color as it grows off the
nail bed, shape of convex curve, smooth and is intact with the epidermis. When
nails pressed between the fingers (Blanch Test), the nails return to usual color in
less than 3 seconds.
7. Ask patient to squeeze you two fingers (the index and middle finger crossing the index
finger) this compare the hands for strength asymmetry.
8. Check radial pulse on each arm
9. Have patient touch each finger to the thumb. (A test for coordination of the movements of
the upper extremities).
10. Have patient hold both arms straight in front of him, assess each arm, have patient make a
muscle and check the brachial pulse that should be right under the bicep in each arm (The
client’s skin should be uniform in color, unblemished and no presence of any foul odor.
Patient has good skin turgor and skin’s temperature is within normal limit).
11. Have patient flex elbows and rotate shoulders in a backward motion. (elbow flexion test
is an elbow examination procedure to test for cubital tunnel syndrome and checking
ROM of the shoulders).
12. Smile and ask patient to smile (is used to check for one-sided facial weakness, a classic
sign of stroke, or the Facial Nerve, also known as cranial nerve VII)
13. The face of the patient should appear smooth and has uniform consistency and with no
presence of nodules or masses.
14. Access the head of the patient, hair should be thick, silky, evenly distributed and has a
variable amount of body hair. (No signs of infection, infestation, head of the patient is
rounded, normocephalic, symmetrical, no skull nodules or masses and depressions when
palpated).
15. Assess the eyes, have patient look at your forehead while shining the pen light in one
pupil (reflex) while watching the opposite pupil, making sure both move together
16. Have patient follow the tip of your pen light, starting with the patient’s nose being the
center of focus and have the patient follow the pen light as you make an “X” and a “+”
sign with the pen light and follow it as you touch the patients nose.
17. Have patient read the small letter, then the large letters on your badge.
18. Have patient cover one eye at a time and check peripheral vision on both eyes.
a. OPTIC Cranial Nerve II (function: visual acuity) Checks EOM (extraocular
muscle) Snellen chart, 20 feet back
, b. OCCULOMOTOR Cranial Nerve III (function: Upward, downward, medial eye
movement, lid elevation, pupil construction) EOM- Cardinal positions, Open
eyes, PERRLA.
c. TROCLEAR Cranial Nerve IV (function: EOM (down / in) Movements that
reflect the inward and downward movement of eye.
d. ABDUCENS Cranial Nerve VI (Function: lateral eye movement) Move object
left/right.
19. Use pen light and check ear shell and the back of the ear (looking for critters or bruising
or cerebrospinal fluid (CSF) and the inside of the ear, critters can come out of ear canal or
live behind the ear. While assessing an ear, test their hearing before moving to the other
ear. Have patient cover the ear on the opposite side, rub your gloved fingers together to
see if the patient can hear it.
a. VESTIBULECOCHLEAR/ACOUSTIC Cranial Nerve VIII (function: hearing
and equilibrium) Whisper/voice test. Weber test (tuning fork on forehead), Rinne
test, (tuning fork on mastoid process), Romberg test (for equilibrium).
20. Assess patients nose, looking for a deviated septum.
21. Have patient close eyes and identify what they are smelling.
a. OLFACTORY Cranial Nerve l (function: smell) Done when loss of smell is
reported, head trauma, change in mental statues. With eyes closed place simple
odor under one nostril at a time while holding another nostril closed. Looking for
asymmetry.
22. Have patient open their mouth and say “ahhh”, have them move their tongue around in
mouth while you look at their teeth and gums. Have them stick their tongue out, move
back and forth, and swallow. After swallowing have them reopen their mouth again and
look inside mouth to make sure they were able to swallow, should be nice and clear, no
spit.
a. GLOSSOPHARYNGEAL, Cranial Nerve IX
Sensory-Taste...posterior 3rd of tongue...too hard to test.
Motor- gag reflex, touch pharynx with cotton applicator.
23. Have patient move their head back and forth as if they are saying “No”, then up and
down like saying “yes”. (wanting to see patients full ROM in the neck).
24. Have your stethoscope ready, and have patient lie down (30 degrees HOB elevation),
look for jugular venous distension (JVD), listen to the carotids for a carotid bruit (is the
unusual sound that blood makes when it rushes past an obstruction in an artery when the
sound is auscultated with the bell portion of a stethoscope)
25. Listen to the trachea and have the patient breath in and out.
26. Palpate each carotid, one at a time.
27. MUST be able to identify the suprasternal notch VERBALLY (U-shaped depression just
above the sternum, in between the clavicles)
28. Costal Angle (there right and left costal margins form an angle where they meet at the
xiphoid process)
29. Angle of Louis (Ribs are counted from this level to downwards. 2nd rib lies at Sternal
angle of Louis).
30. Auscultate aortic, pulmonic, tricuspid, and mitral area using correct anatomical
landmarks.
1. Walk in and sanitize your hands while introducing yourself.
2. Let patient know you are going to be their nurse today.
3. Verify patients name, date of birth, and if any allergies?
4. Inform patient it’s time for their assessment which involves putting your stethoscope on
them and you will be asking then to do a few tasks for you, “is that okay?”
5. Put gloves on for assessment. (“how are you feeling today, any pain”)
6. Ask patient to see both hands and explain you are checking for capillary refill.
a. Nails: Healthy fingernails and toenails should generally be a pink color - with the
healthy nail plate being pink, and the nail being white in color as it grows off the
nail bed, shape of convex curve, smooth and is intact with the epidermis. When
nails pressed between the fingers (Blanch Test), the nails return to usual color in
less than 3 seconds.
7. Ask patient to squeeze you two fingers (the index and middle finger crossing the index
finger) this compare the hands for strength asymmetry.
8. Check radial pulse on each arm
9. Have patient touch each finger to the thumb. (A test for coordination of the movements of
the upper extremities).
10. Have patient hold both arms straight in front of him, assess each arm, have patient make a
muscle and check the brachial pulse that should be right under the bicep in each arm (The
client’s skin should be uniform in color, unblemished and no presence of any foul odor.
Patient has good skin turgor and skin’s temperature is within normal limit).
11. Have patient flex elbows and rotate shoulders in a backward motion. (elbow flexion test
is an elbow examination procedure to test for cubital tunnel syndrome and checking
ROM of the shoulders).
12. Smile and ask patient to smile (is used to check for one-sided facial weakness, a classic
sign of stroke, or the Facial Nerve, also known as cranial nerve VII)
13. The face of the patient should appear smooth and has uniform consistency and with no
presence of nodules or masses.
14. Access the head of the patient, hair should be thick, silky, evenly distributed and has a
variable amount of body hair. (No signs of infection, infestation, head of the patient is
rounded, normocephalic, symmetrical, no skull nodules or masses and depressions when
palpated).
15. Assess the eyes, have patient look at your forehead while shining the pen light in one
pupil (reflex) while watching the opposite pupil, making sure both move together
16. Have patient follow the tip of your pen light, starting with the patient’s nose being the
center of focus and have the patient follow the pen light as you make an “X” and a “+”
sign with the pen light and follow it as you touch the patients nose.
17. Have patient read the small letter, then the large letters on your badge.
18. Have patient cover one eye at a time and check peripheral vision on both eyes.
a. OPTIC Cranial Nerve II (function: visual acuity) Checks EOM (extraocular
muscle) Snellen chart, 20 feet back
, b. OCCULOMOTOR Cranial Nerve III (function: Upward, downward, medial eye
movement, lid elevation, pupil construction) EOM- Cardinal positions, Open
eyes, PERRLA.
c. TROCLEAR Cranial Nerve IV (function: EOM (down / in) Movements that
reflect the inward and downward movement of eye.
d. ABDUCENS Cranial Nerve VI (Function: lateral eye movement) Move object
left/right.
19. Use pen light and check ear shell and the back of the ear (looking for critters or bruising
or cerebrospinal fluid (CSF) and the inside of the ear, critters can come out of ear canal or
live behind the ear. While assessing an ear, test their hearing before moving to the other
ear. Have patient cover the ear on the opposite side, rub your gloved fingers together to
see if the patient can hear it.
a. VESTIBULECOCHLEAR/ACOUSTIC Cranial Nerve VIII (function: hearing
and equilibrium) Whisper/voice test. Weber test (tuning fork on forehead), Rinne
test, (tuning fork on mastoid process), Romberg test (for equilibrium).
20. Assess patients nose, looking for a deviated septum.
21. Have patient close eyes and identify what they are smelling.
a. OLFACTORY Cranial Nerve l (function: smell) Done when loss of smell is
reported, head trauma, change in mental statues. With eyes closed place simple
odor under one nostril at a time while holding another nostril closed. Looking for
asymmetry.
22. Have patient open their mouth and say “ahhh”, have them move their tongue around in
mouth while you look at their teeth and gums. Have them stick their tongue out, move
back and forth, and swallow. After swallowing have them reopen their mouth again and
look inside mouth to make sure they were able to swallow, should be nice and clear, no
spit.
a. GLOSSOPHARYNGEAL, Cranial Nerve IX
Sensory-Taste...posterior 3rd of tongue...too hard to test.
Motor- gag reflex, touch pharynx with cotton applicator.
23. Have patient move their head back and forth as if they are saying “No”, then up and
down like saying “yes”. (wanting to see patients full ROM in the neck).
24. Have your stethoscope ready, and have patient lie down (30 degrees HOB elevation),
look for jugular venous distension (JVD), listen to the carotids for a carotid bruit (is the
unusual sound that blood makes when it rushes past an obstruction in an artery when the
sound is auscultated with the bell portion of a stethoscope)
25. Listen to the trachea and have the patient breath in and out.
26. Palpate each carotid, one at a time.
27. MUST be able to identify the suprasternal notch VERBALLY (U-shaped depression just
above the sternum, in between the clavicles)
28. Costal Angle (there right and left costal margins form an angle where they meet at the
xiphoid process)
29. Angle of Louis (Ribs are counted from this level to downwards. 2nd rib lies at Sternal
angle of Louis).
30. Auscultate aortic, pulmonic, tricuspid, and mitral area using correct anatomical
landmarks.
