Health Assessment Student Skills Check Off PDF

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INTEGRATED BEDSIDE PHYSICAL EXAM CHECK OFF GUIDE Student Name: ___________________

Behavior Evaluated

Date/ Satisfactory (S)/ Instructor Unsatisfactory(U)/ Initials Comments

Enter Room: Introduce self to the client and explain what you will be doing: 1. Perform Hand Hygiene 2. Verify patient’s name on identification band 3. Provide Privacy 4. Ask about pain or discomfort and to rate pain using appropriate scale 5. Assess the general survey/appearance -facial expression, eye contact -level of consciousness (e.g. level of orientation sedation) -body position -note skin color and tone, -nutritional status (initial visual assessment), -personal hygiene -clothing/dress. 6. Measure baseline vital signs: -verbalize only measurement of: temperature, radial pulse, respirations, blood pressure, pulse oximetry readings noting supplemental oxygen mode and FiO2 7. Inspect head and face -facial expression, -symmetry (verbalize testing cranial nerve VII) -skin

8. Assess the eyes -inspect external eye (brows, lids, lashes, and

Separate check off form for vital signs Must be completed by due date

lacrimal apparatus) & Inspect conjuctivas, scleras, cornea, and irises -test visual fields by confrontation and extinction (verbalize testing cranial nerve II) -test extraoccular muscles: corneal light reflex, 6 cardinal positions of gaze (verbalize testing cranial nerves III, IV, VI) -test pupil: size, response to light (direct/consensual) and accommodation 9. Assess the ears -inspect the external ear: position and alignment, skin condition, and auditory meatus 10. Assess the nose - inspect the external nose: symmetry, lesions - inspect the nares: nasal mucosa, and septum 11. Assess the mouth and throat - using a penlight, inspect the mouth: buccal mucosa, teeth and gums, tongue, frenulum, floor of mouth, palate, and uvula - assess gag reflex and ability to swallow (verbalize testing Cranial nerves IX, X) - ask the person to stick out the tongue (position, color, texture) - listen to articulation of words (verbalize testing Cranial nerve XII) 12. Assess the neck -inspect the neck: symmetry, lumps, and pulsations - inspect and palpate the carotid pulse, one side at a time. -listen for carotid bruits -palpate the trachea in midline -test range of motion and muscle strength against your resistance: head forward and back, head turned to each side, and shoulder shrug (verbalize testing Cranial nerve XI)

Step around behind the person. Open the gown to expose all of the back, but leave gown on shoulders and anterior

chest 13. Assess the posterior and lateral chest -inspect the posterior chest: configuration of the thoracic cage, skin characteristics, and symmetry of shoulders, muscles, and chest expansion -palpate: lumps, tenderness, masses -auscultate breath sounds (vesicular, bronchovesicular, bronchial) and note if any adventitious breath sounds if present Move around to face the person: the person remains sitting. For a female, ask and lift gown to drape on shoulders, exposing the anterior chest; for a male, lower the gown to the lap 14. Assess the anterior chest -inspect symmetrical chest expansion, -respiratory effort (depth, rhythm, and use of accessory muscles) -skin characteristics -Auscultate breath sounds 15.Assess the upper extremities -test range of motion and muscle strength of hands, arms, and shoulders -check hand grips -assess nail beds- cap refill bilaterally -palpate brachial, radial pulse Have client lie down 16. Inspect the neck vessels for jugular venous distention -HOB at 30-45 degrees

17. Assess the heart -inspect the precordium for pulsations and retractions

-palpate the apical impulse, and auscultate/count the apical pulse -auscultate the rate and rhythm 5 sites -auscultate with the diaphragm to study heart sounds, inching from the apex up to the base, or vice versa -auscultate the heart sounds with the bell, again auscultating the apex up to base or vise versa -verbalize position change (turn patient to the left side or lean forward) if difficulty with heart sound auscultation -describe location, timing, quality, of abnormal sounds if present 18. Abdomen -auscultate bowel sounds all four quadrants -inquire about last bowel movement -palpate: light palpation of all four quadrants -palpate for rebound tenderness -verbalize/palpate each groin for the femoral pulse, inguinal nodes palpate: deep palpation of all four quadrants -assess voiding frequency or urinary catheter -assess color and clarity of urine 19.Assess the lower extremities Lift up the drape to expose the legs -inspect: symmetry, skin characteristics, and hair distribution -test range of motion and muscle strength of feet, ankles, and legs -palpate pulses: popliteal, posterior tibial, dorsalis pedis -palpate for temperature and edema -assess capillary refill to toes bilaterally -inspect legs for varicose veins 20. Assess Gait

-if gait not witnessed previously, ask the person to walk across the room For the hospitalized person, answer any questions, return the bed and any room equipment to the way you found it. Make the call light and telephone in easy reach.

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