DELAWARE TECHNICAL & COMMUNITY COLLEGE
TERRY CAMPUS, NURSING DEPARTMENT NUR 271 NURSING CARE OF ADULTS IV
NUR 271 PHYSICAL ASSESSMENT Yes GENERAL SURVEY General appearance Behavior Posture Gait Hygiene Speech Mental status Nutritional status HEAD AND FACE Inspect s in characteristics Inspect symmetry and e!ternal characteristics o" eyes and ears Inspect hair "or te!ture# distri$ution# and %uantity o" hair Inspect a$ility to open &a' and clench teeth as you palpate the masseter muscle# s%uee(e eyes tightly shut# raise eye$ro's# smile# pu"" out chee s )CN * + trigeminal# *II + "acial, EYES Inspect eyelids# eyelashes Inspect sclerae# con&unctivae Assess visual "ields )CN II - optic nerve, .est e!traocular eye movements )CN III + oculomotor# I*+ trochlear# *I + a$ducens, .est pupillary response to light and accommodation EARS Inspect alignment Inspect sur"ace characteristics Assessed Appropriately? No Comments
2 .est hearing - have pt/ cover one ear 'hile you 'hisper a num$er in the other/ Have them repeat the num$er )CN *III - vesti$ulocochlear,
3 MOUTH AND PHARYNX Inspect lips# $uccal mucosa# gums# hard and so"t palates# "loor o" the mouth "or color and sur"ace characteristics0dentition Inspect oropharny!1 uvula# tonsils# posterior pharyn!# mouth odor Have pt/ stic out tongue straight and then move "rom side to side/ Inspect tongue "or color# characteristics# symmetry# movement )CN 2II + hypoglossal, .est 3ah4 re"le! )palate articulation, )CN I2 - glossopharyngeal, As pt to s'allo' )or test gag re"le!, )CN 2 - vagus, NECK Inspect "or symmetry and smoothness o" nec and thyroid Inspect "or &ugular venous distention Per"orm active range o" motion5 test resistance pushing their head against e!aminers hand .est strength o" shoulder shrug )CN 2I - accessory nerve, Palpate carotid pulses5 only one side at a time6 Palpate thyroid# as pt/ to s'allo' Palpate tracheal position Auscultate carotid arteries UPPER EXTREMITIES Inspect hands# arms# shoulders Inspect s in characteristics Inspect nail characteristics Palpate hands# arms# shoulders "or muscle tone0 de"ormity Per"orm assessment o" 78M+'rists# el$o's# shoulders Assess muscular strength Palpate radial and $rachial pulses ANTERIOR CHEST, LUNGS, AND HEART Inspect s in Inspect respiratory e""ort0depth# rhythm# and pattern Palpate chest 'all "or sta$ility# crepitation# tenderness# pulsations Auscultate systematically "or $reath sounds Auscultate systemically "or heart sounds1 aortic area# pulmonic area# 97BS point# tricuspid area# mitral area Inspect "or musculos eletal de"ormity Yes No Comments
4 Yes BACK AND POSTERIOR CHEST Inspect s in o" posterior thora! and spine Inspect posterior thora! and spine "or musculos eletal symmetry Palpate thora! and spinal process Auscultate systematically "or $reath sounds ABDOMEN Inspect s in characteristics# contour# pulsations# movement Identi"y organs in appropriate %uadrant Auscultate all %uadrants "or $o'el sounds Identi"y the renal and iliac arteries Percuss all %uadrants "or tone :ightly palpate all %uadrants ;eeply palpate all %uadrants INGUINAL AREAS Palpate "emoral pulses FEET AND LEGS Inspect "eet# calves# thighs# hips Inspect "or s in characteristics Inspect nail characteristics Inspect "or hair distri$ution Inspect "or muscle tone0de"ormities Palpate "or temperature# te!ture# edema Per"orm assessment o" 78M o" "eet# an les# nees# and hips Assess muscular strength# hips# nees# an les# "eet Palpate dorsalis pedis# posterior ti$ial# and popliteal pulses
S9M0p'0<==>+?0A;N+<@?0Physical Assessment )A+?=+=<, 7evised BC0p'0<==>+? )?=+<D+=<,5 9S0p'0<==D+? )A+A+=>, 7evised 7S0<=??
No
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