🔹Physical assessment components

Question 1

Pain assessment PQRST (subjective)

Answer 1

1. P roactive/ palliative factors. What works to relieve pain?
2. Quality-
3. Region/ radiation? (Location)
4. Severity? (intensity 1-10 scale)
5. Timing ? (onset, frequency, duration)
6. How is pain affecting you?

Question 2

Pain (objective)

Answer 2

• nonverbal (facial grimacing, guarding)

- nonverbal pain scale

Question 3

Neuro assessment Subjective

Answer 3

• alert and oriented to person, place, time?
• swallowing liquids or solids (w/out coughing or choking?)
• memory intact (3 words)

Question 4

Neuro assessment objective

Answer 4

• behavior appropriate to situation
• thought process coherent (logical & organized)
• verbalization clear and understandable
• able to hear the spoken word
• pupils equal, round, react briskly to light PERRL
• hand grasps strong and equal

Question 5

Cardio subjective

Answer 5

• chest discomfort?

- calf tenderness?

Question 6

cardio objective

Answer 6

• apical pulse regular
• S1 and S2 present (name and locate each heart area)
• neck veins flat at 45 deg
• Capillary refill time < 3 seconds all extremities
• peripheral pulses strong , equal, palpable
• no edema

Question 7

respiratory subjective

Answer 7

• SOB?

- Sputum COCA

Question 8

respiratory objective

Answer 8

• cough strong, dry, non-productive
• respirations are regular, even and unlabored
• lungs clear ( no adventitious sounds) in all lobes bilaterally, anterior & posterior
• nail beds and mucous membranes PINK

Question 9

Gastrointestinal subjective

Answer 9

• passing gas?
• tolerates prescribed diet w/out N&V?
• BMs within own normal pattern and consistency…..X day
• last BM ? COCA
• pain?

Question 10

Gastrointestinal objective

Answer 10

• oral cavity and teeth healthy
• abdomen flat with no distention ( supine)
• bowel sounds (5-34/min)
• abdomen soft, non-tender with palpation

Question 11

Urinary subjective

Answer 11

• continent of urine?
• able to empty bladder w/out: dysuria, urgency, frequency, nocturia
• urine COCA

Question 12

Urinary objective

Answer 12

Bladder not distended after voiding

Question 13

Integumentary subjective

Answer 13

• skin lesions, bruises, or rashes

Question 14

Integumentary objective

Answer 14

• skin color? - pink or normal for individual
• skin warm, dry and intact
• no rashes, bruises , ulcerations
• mucous membranes moist
• hair supple & intact
• nail surface smooth, intact w/out clubbing
• skin turgor < 3 sec

Question 15

Musculoskeletal subjective

Answer 15

• painful joints
• painful muscles
• tremors
• tolerates activity

Question 16

Musculoskeletal objective

Answer 16

• active ROM of all extremities with symmetry of strength
• major joints: flexion, extension, abduction, adduction
• steady gait , upright posture

Question 17

Peripheral neurovascular assessment CMS subjective

Answer 17

Assess affected extremity:

• pain
• numbness
• tingling
• describe deficit if present

Question 18

Peripheral neurovascular assessment CMS objective

Answer 18

• circulation intact :
  
  • pink
  • warm
  • pulse(s) present
  • no edema
  • cap refill <3 sec to affected areas
• ROM with PTs
• sensation present in extremity