NUR 250 Physical Assessment Checklist

Question 1

Assessor Checklist (6)

Answer 1

1. introduces self appropriately
2. Performs hand hygiene
3. Patient verification (2 identifiers)
4. Conducts basic vital sign assessment dont have to do
5. Explains assessment to patient
6. Review medications, allergies and asks about concerns
7. Reviews past medical history

Question 2

General appearance

Answer 2

8. assess overall apperence

Question 3

Neuro (7)

Answer 3

9. Obtains Glasgow Coma Scale
10. Assess Level of Consciousness (LOC) orientation to person, place and time, cognition, and memory (ask why they are in the hospital)
11. As you are speaking with the patient note any slurred speech of facial droop (Verbalize this aloud)
12. assess pupils
13. Ask the patient if they are having any headaches
14. Asks patient if they are having any dizziness
15. Assess for language barrier

Question 4

Graded Motor Strength Scale (4)

Answer 4

16. Checks for strength with grips
17. Checks for movement in all 4 extremities
18. checks for use of feet to move against resistance
19. Asks patient if they can walk, assess gait/balance (*if appropriate)

Question 5

HEENT (6)

Answer 5

20. Inspect face, head for shape, symmetry
21. Inspects external nose and lips and oral mucosa
22. Inspects neck, trachea, and thyroid
23. Inspect external ears and nose for drainage
24. Ask patient if they wear dentures
25. Ask patient if they have had any swallowing or difficulty chewing

Question 6

Respiratory (7)

Answer 6

26. Assess respiratory pattern
27. Auscultates breath sounds anterior and posterior (under the gown)
28. Evaluates use of accessory muscle
29. Notes chest excursion is symmetrical (Verbalize this aloud)
30. Any cough/sputum production (amount, color, consistency)
31. Assess for shortness of breath or dyspnea
32. Assess if position impacts breathing

Question 7

Cardiac (5)

Answer 7

33. Listens to heart sounds (under the gown)
34. S1, S2, gallop or murmurs
35. Assess cardiac rhythm, regularity, and rhythm tolerance
36. Examines for JVD
37. Asks If patient is having chest pain

Question 8

Peripheral vascular (4)

Answer 8

38. Assess for edema (BIL UE and LE) (Verbalize this aloud)
39. Capillary refil
40. Assess peripheral pulses, radial, dorsalis pedis, posterior tibial (BIL UE and LE)
41. Assess IV site if applicable (verbalize site assessment aloud)

Question 9

GI (5)

Answer 9

42. Inspects abdomen (soft, non tender, non distended)
43. Auscultates bowel sounds
44. Palpates abdomen for tenderness
45. Asks patient last bowel movement
46. Ask patients if they are experiencing any nausea, vomiting, constipation, or diarrhea

Question 10

GU (4)

Answer 10

47. Assess pain or burning upon urination
48. Assess continence of patient
49. Assess color, odor or urine
50. Assess for urinary diversions (foley, suprapubic catheter, ureterostomy)

Question 11

Integumentary (3)

Answer 11

51. Assess skin color, condition, temp, integrity (Verbalize this aloud)
52. Assess for tenting
53. Assess if skin is free of any lesions, wounds, bruises, abrasions, avulsions, rashes, or other abnormalities

Question 12

Safety (7)

Answer 12

54. Bed in low position
55. Call light within reach
56. Space clutter free
57. Personal belongings within reach
58. Slip resistant socks
59. Conclude exam
60. Closes with professional comments dont have to do
61. Thanks the patient for exam
62. Student looks and acts professional during exam *dont have to do