CPE A: Physical Assessment
Announce “Hi my name is….
Wash your hands.
Identify (2 identifiers, Name and DOB)
Privacy (Pull the curtain for privacy)
Educate (tell your patient what is about to happen such as procedure
and assessments)
Neurological:
Assess orientation to person, place (location), and time (todays
date). Patient response to simple commands such as
HET: Head, Eyes and Throat/Mouth
Assess the head: hair distribution, inspect the scalp (checking for
lesions, DO NOT VERBALIZE)
Assess the eyes: PERRLA (pupils are round reactive to light and
accommodate) and assess the sclera and conjunctiva.
Assess the mouth and throat: Inspect the lips and the oral
mucosa (color, lesion, moistness) Inspect hygiene care as well.
INTEGUMENTARY:
Palpate and inspect the skin surfaces for moisture, texture,
temperature, turgor, lesions (ABCDE if lesions are present),
tenderness, color (normal for ethnicity)
Inspect and palpate areas of the body for edema (feet, ankles
and sacrum) Palpate edematous areas for tenderness VERBALIZE
THIS!
Assess sensation bilaterally (sharp or dull)
Assess the palms of the hands, nails beds and fingernails.
Assess capillary refill on fingers and toes.
Assess and palpate brachial and radial pulses.
TLC: Thorax, Lungs, and Carotid
Inspect thorax for size, symmetry (shape) AP diameter (1 hand
deep: to 2 hands wide) and expansion (tactile fremitus)
Palpate and visualize the spinal alignment.
Recognize landmarks such as trachea, suprasternal notch (top of
manubrium), angle of louis (second intercoastal space) and
costal angle (locate xiphoid process place thumbs and fingers
underneath the breast area <90 degrees)
Instruct patient to breathe deeply and through the mouth while
auscultating the lungs.
Move stethoscope side to side anteriorly and posteriorly (10
areas each systematically S motion; LISTENING TO THE APEX OF
THE LUNGS AND THE BASE) to auscultate all lobes (verbalize
these: tracheal, bronchial, vesicular, and bronchovesicular.
CARDIO:
Announce “Hi my name is….
Wash your hands.
Identify (2 identifiers, Name and DOB)
Privacy (Pull the curtain for privacy)
Educate (tell your patient what is about to happen such as procedure
and assessments)
Neurological:
Assess orientation to person, place (location), and time (todays
date). Patient response to simple commands such as
HET: Head, Eyes and Throat/Mouth
Assess the head: hair distribution, inspect the scalp (checking for
lesions, DO NOT VERBALIZE)
Assess the eyes: PERRLA (pupils are round reactive to light and
accommodate) and assess the sclera and conjunctiva.
Assess the mouth and throat: Inspect the lips and the oral
mucosa (color, lesion, moistness) Inspect hygiene care as well.
INTEGUMENTARY:
Palpate and inspect the skin surfaces for moisture, texture,
temperature, turgor, lesions (ABCDE if lesions are present),
tenderness, color (normal for ethnicity)
Inspect and palpate areas of the body for edema (feet, ankles
and sacrum) Palpate edematous areas for tenderness VERBALIZE
THIS!
Assess sensation bilaterally (sharp or dull)
Assess the palms of the hands, nails beds and fingernails.
Assess capillary refill on fingers and toes.
Assess and palpate brachial and radial pulses.
TLC: Thorax, Lungs, and Carotid
Inspect thorax for size, symmetry (shape) AP diameter (1 hand
deep: to 2 hands wide) and expansion (tactile fremitus)
Palpate and visualize the spinal alignment.
Recognize landmarks such as trachea, suprasternal notch (top of
manubrium), angle of louis (second intercoastal space) and
costal angle (locate xiphoid process place thumbs and fingers
underneath the breast area <90 degrees)
Instruct patient to breathe deeply and through the mouth while
auscultating the lungs.
Move stethoscope side to side anteriorly and posteriorly (10
areas each systematically S motion; LISTENING TO THE APEX OF
THE LUNGS AND THE BASE) to auscultate all lobes (verbalize
these: tracheal, bronchial, vesicular, and bronchovesicular.
CARDIO:
