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Physical Assessment

This document outlines the required components for conducting a physical assessment as part of the nursing process. It lists assessment areas for general survey, head and neck, upper extremities, thorax/respiratory, cardiac, abdomen, and lower extremities. For each area, it specifies physical exam maneuvers and assessments including inspection, palpation, percussion, and auscultation. The goal is to provide a comprehensive head-to-toe assessment of the patient through examination of various body systems and regions.

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Feyd1972
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160 views

Physical Assessment

This document outlines the required components for conducting a physical assessment as part of the nursing process. It lists assessment areas for general survey, head and neck, upper extremities, thorax/respiratory, cardiac, abdomen, and lower extremities. For each area, it specifies physical exam maneuvers and assessments including inspection, palpation, percussion, and auscultation. The goal is to provide a comprehensive head-to-toe assessment of the patient through examination of various body systems and regions.

Uploaded by

Feyd1972
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Physical Assessment

Required Components
Nursing Process

Required Components
General 1. General appearance & behavior
survey 2. Posture
3. Gait
4. Hygiene
5. Speech
6. Mental Status
7. Vital Signs
8. Nutritional Status

Head and 1. Symmetry


Neck 2. Head & hair
3. Ears/Hearing
4. PERRL(A)
5. EOM
6. Convergence/Accommodation
7. Color/condition conjunctiva
8. Color/condition of mucus membranes
9. Nose
10. Mouth/teeth
11. ROM of neck
12. Cervical nodes
13. Palpate trachea for symmetry
14. Carotids, auscultate optionally
15. JVD

Upper 1. Skin – condition,


extremities 2. Palpate for temperature, sensation,
muscle tension/firmness
3. Capillary refill
4. Turgor
5. Pulses
6. Strength
7. ROM

Rvsd 5-25-10
Thorax/ 1. Inspect Thoracic expansion, symmetry
Respiratory 2. Inspect respiratory pattern
3. Palpate for tenderness, symmetry, and
fremitus
4. Auscultate normal & abnormal sounds
5. Auscultate breath sounds (identify areas
for normal breath sounds A & P)
6. Discuss anatomy
Cardiac 1. Inspect for abnormal pulsations
2. Palpate PMI
3. Auscultate heart sounds, identify sites,
normal sounds, terminology
4. Discuss anatomy

Abdomen 1. Inspect for symmetry, pulsations, bladder


distention
2. Auscultate for Bowel Sounds X 4
3. Light palpation for surface lumps or
nodules
4. Discuss/demonstration assessment for
abdominal pain
5. Discuss underlying anatomy

Lower 1. Inspect Skin – condition, hair


Extremities distribution.
2. Palpate for temperature, sensation,
muscle tension/firmness
3. Capillary refill
4. Pulses
5. Pedal and Ankle Edema
6. Strength, dorsal and plantar flexion
7. ROM
8. Homan’s Sign

Rvsd 5-25-10

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