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Physical Assessment Sample Guide #1 UPDATED 06162021-RECENT.docx

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N190 Physical Assessment Practicum Quick Sample Guide 2021I. SOW/INTRO/PAE/5 QuestionsAction(s)Verbalization1.Supplies gathered/Orders checked/Washed hands/Privacy provided/Adjusted bed/ Environmental safety checked:Knock2.Introduce Self:Explain procedure to be done“I will be doing PA, Will be touching u, Asking you to move about, Is that OK?”3.Pt’s ID /Allergy:Look at Pt.’s ID band“Please state your complete name and DOB, Any allergies?”4.Assess orientation X4:ASK“Who is the president of US, What time, Why are you here, Where are you?”5. Assess mood/wellbeing:ASK“Do you feel safe here, Do you feel safe at home, Tried to hurt yourself or others?”6. Assess for pain:ASK“Do you have any pain in any part of your body?”7. Vital signs already taken:Verbalize“Vital signs within normal Limits, no abnormal findings, documented”
II. Head to JVD (8)1. Hair & Skin inspection-Separate hair 1 inch apart @ a time all around crown of the head, Then Run fingers of both handsthrough the scalp and palpate head, With the Dorsal part of your hands feel skin from forehead to neck -“No infestations, Head-No mass on palpation, Skin warm, dry & Intact, even color, pink undertone, No lesions, scars, tattoos, No edema (press bonypart offace- mandible area), No skin tinting (pinch below the clavicle).”2. Inspect Ears-Pull Pinna up and back (Right and Left side), use penlight, then examine-“Both ears clean, No drainage, No lesions,No occlusion.”3. Inspect Nose & Inspect Mouth-Inspect Right and Left Nostrils, Open Mouth, Use penlight-Nasal septum-straight, intact, nodeviation, no polyps, no lesion, no drainage or occlusions.”Mouthopen wide, exposing upper and lower teeth, uvula & Ask PT to say“aaah- Inspect with tongue depressor if PT unable to open mouth wide. “Mucosa pink & moist, No lesions, uvula midline, softpalate symmetrical, complete set of teeth, no teeth cavities, no swollen gums, tongue - top & underneath - pink & moist, no lesionsor swelling noted”4. Neck -Inspect& Palpate Neckwith finger pads of one hand:Trachea-Lightly Hold Trachea with the thumb & finger pads ofdominant hand & ask patient to swallow;Thyroid-At the middle part of the neck anteriorly, Push Thyroid on one side and palpatewith finger pads onthe opposite side (Avoid the carotid arteries ), Repeat on the other side push and palpate. “No mass or bulgingin the neck, Able to swallow w/o difficulty. Trachea midline; On palpation of thyroid – Thyroid soft & smooth, no mass palpated orpain elicited.”5. 10 Lymph Nodes-Palpate 10 lymph nodes- Gentle Circular Motions -“No swollen lymph nodes noted” (Pre-auricular, Post-auricular, Occipital, Submental, Submandibular, Retropharyngeal, Anterior Cervical Chain, Deep Cervical Chain, Posterior Cervical,Supraclavicular).6. Carotid Arteries –Palpate Carotid Arteries one at a time first, then Auscultate C. Arteries for Bruit-Feel for Carotid Arteries oneat a time-Auscultate Carotid Arteries using (BELL) while PT faces slightly leaning towards the Bell, Ask PT to deep breath & hold

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