Abdomen Assessment
Wash hands, gather equipment, knock on door, ID self, greet client, perform general survey including - resp effort, skin color, LOC, demeanor,
nutrition, symmetry, posture, position, gait, range of motion, dress, personal
hygiene, speech; Ask client name/DOB and compare to order/armband; Must assess for orientation to place, time and situation; Must perform environmental survey looking at bed rails up, bed being locked, call light w/in reach, nothing in the floor, well-lit room; Explain procedure and gain permission; Use pain scale featuring PQRSTU; Inspect contour, symmetry, umbilicus, skin, pulsation, and demeanor, Auscultate bowl sounds and describe; Percuss bowl sounds in all 4 quad’s and describe; Palpate in all 4 quad’s and describe; Explain pt you will be back to check on them; Perform hand hygiene before leaving the room; Make sure to verbalize findings throughout assessment
Ears Assessment
Wash hands, gather equipment, knock on door, ID self, greet client, perform general survey including - resp effort, skin color, LOC, demeanor, nutrition, symmetry, posture, position, gait, range of motion, dress, personal hygiene, speech; Ask client name/DOB and compare to order/armband; Must assess for orientation to place, time and situation; Must perform environmental survey looking at bed rails up, bed being locked, call light w/in reach, nothing in the floor, well-lit room; Explain procedure and gain permission; Inspect external ear for skin condition, size, symmetry, and shape and report findings; Identify and palpate external ear structures (auricle or pinna) (tragus, lobule, helix, mastoid process, external auditory meatus) for masses, lesions, and tenderness and report findings; Use a penlight and retract the adult ear up and back; Inspect auditory meatus for foreign bodies, discharge, and cerumen
(describe if found) and report findings; Test hearing acuity using whispered voice test; Assesses Cranial nerve VIII Report findings; Explain to your pt you will be back to check on them; Perform hand hygiene upon exiting the room
Head/Face/Neck Assessment
Wash hands; Gather and prepare equipment; Knocks on door, enters client’s room with supplies, identify self, greet client,
provides for privacy; Wash Hands; Perform general survey: Assess resp effort, skin color, LOC, demeanor,
nutrition, symmetry, posture, position, gait, range of motion, dress, personal hygiene, speech; ID client using 2 identifiers: (Establish communication with client)
Ask name & DOB comparing to order & ID band; check ID band number; Assess orientation to place, time, situation; Performs Environmental Survey: Bedrails up, bed low position, clear floors,
personal items within reach, bed alarm as needed, well lit room; Explains procedure and purpose; Obtains permission from client; Performs pain Assessment: Uses numeric scale appropriately. Uses PQRSTU if pain identified; Inspect and palpate the skull (symmetry, size, contour, deformities
(lumps, depressions and abnormal protrusions), position, and
tenderness). Describe; Palpate the temporal artery bilaterally. Report findings. Grade 0-4+; Palpate the temporomandibular joint bilaterally for motion,
limitations, and tenderness. Report findings; Palpate the maxillary sinuses and frontal sinuses for tenderness; Report findings; Inspect the face (expression, edema, involuntary movements, lesions,
pigmentation, and symmetry of: eyebrows, palpebral fissures,
nasolabial folds, sides of mouth); Describe each structure
Inspect and palpate the neck (symmetry, lumps, pulsations, head
position, tenderness). Report findings; Palpate carotid pulses for symmetry, regularity, and strength. Grade 0-4; Inspect, palpate, and identify anterior and posterior lymphatic chains
in neck area for size, delimitation (discreet/together), mobility, and
tenderness.
preauricular, postauricular, occipital posterior cervical chain, submental (one finger palpation only), submandibular (submaxillary) superficial cervical, deep cervical chain, supraclavicular; Explain to patient you will be back to check on them. Ensure safety; Perform hand hygiene upon exiting the room; Verbalized findings throughout assessment FVAG
5.5
Mandatory Critical Behavior
Eye Assessment
Wash Hands; Gather and prepare equipment before going into room:
1. Snellen Chart 2. Near Vision Card 3. Penlight 4. Gloves; Knocks on door, enter client’s room with supplies, identify self, greet client; Wash Hands/Don Gloves; Perform general survey: Assess resp effort, skin color, LOC, demeanor,
nutrition, symmetry, posture, position, gait, range of motion, dress, personal
hygiene, speech; ID client using 2 identifiers: (Establish communication with client)
Ask name & DOB comparing to order & ID band; check ID band number; Assess orientation to place, time, situation; Performs Environmental Survey: Bedrails up, bed low position, clear floors,
personal items within reach, bed alarm as needed, well lit room; Explains procedure and purpose; Obtains permission from client; Performs pain Assessment: Uses numeric scale appropriately. Uses PQRSTU
if pain identified; Assess visual acuity using the Snellen chart and near vision testing; Assesses Cranial nerve II; Test visual fields by confrontation test; Inspect EOM function using diagnostic positions test; Assess Cranial
nerve III, IV, VI, Report findings; Inspect external eye structures (symmetry, eyebrows, eyelids and
lashes, eyeballs, conjunctiva (pull lower lid down and have patient look up) and sclera. Describe each structure; Inspect the cornea and iris (shape, and equality). Describe. Explain to patient you will be back to check on them. Ensure safety. Perform hand hygiene upon exiting the room. Verbalized findings throughout assessment
