Physical assessment on a adult
maryyy05
FundamentalsadjustedATIPhysicalAssessment-Adult.pdf
ATITESTING.COM 800.667.7531
Item Check/initial Comments
Verify order Patient record
Assess for procedure need
Identify, gather, and prepare equipment and supplies
Level of consciousness, general patient survey, vital signs (height and weight scale, body mass index calculator, pulse oximeter, thermometer, stethoscope, blood pressure equipment)
Integument (wound measuring device, tape measure)
Head, face, neck (penlight, cotton ball)
Eyes (penlight, ophthalmoscope)
Ears, nose, throat (otoscope, penlight, tongue blade, fragrance)
Respiratory (stethoscope)
Cardiac (stethoscope, penlight)
Abdominal (stethoscope)
Musculoskeletal
Neurological (fragrance, penlight, reflex hammer, tongue blade, cotton ball, low-frequency tuning fork, monofilament)
Apply principles of aseptic practice
Hand hygiene
Personal protective equipment
Disposal of waste
Student’s name Date
For faculty use only Date
Educator’s name
Score
ATI Skills Modules Checklist for Physical Assessment (Adult)
Copyright © 2013 Assessment Technologies Institute®, LLC. All rights reserved. ATITESTING.COM 800.667.7531
ATITESTING.COM 800.667.7531
Item Check/initial Comments
Communicate effectively
Privacy
Patient identification
Patient teaching
Provide for a safe environment
Body mechanics
Equipment placement
Patient safety
Copyright © 2013 Assessment Technologies Institute®, LLC. All rights reserved. ATITESTING.COM 800.667.7531
ATITESTING.COM 800.667.7531
Demonstrate procedural steps
Item Task Check/initial Comments
Level of consciousness, general patient survey, vital signs
Assess level of consciousness.
Assess orientation.
Note general body structure, height, weight, and BMI.
Observe posture and position.
Note facial expression.
Note hygiene, grooming, and dress.
Note odors.
Note mobility aids, medical equipment, dressings, and ostomies.
Note mood and affect.
Assess for pain.
Measure oxygen saturation.
Assess temperature, pulse, respiration, and blood pressure.
Integument Inspect head and scalp for color, hair distribution, and lesions.
Inspect for infestations.
Inspect and palpate skin for texture, moisture, and temperature.
Pinch skin fold over clavicle to check skin turgor.
Note body-hair distribution on legs.
Assess any wounds or lesions.
Inspect for edema.
Inspect nails of feet and hands.
Check for clubbing.
Check capillary refill.
Inspect skin on posterior surfaces.
Check for blanching on any reddened areas.
Head, face, neck Inspect head for size and shape, placement of features, and hair distribution.
Examine face for symmetry.
Observe skin of face.
Palpate skull and hair.
Test cranial nerve V by asking patient to bite down then close his eyes and report light touch.
Examine neck.
Palpate carotid arteries.
Check for thyroid enlargement.
Check range of neck motion.
Observe for jugulovenous distention.
Copyright © 2013 Assessment Technologies Institute®, LLC. All rights reserved. ATITESTING.COM 800.667.7531
ATITESTING.COM 800.667.7531
Demonstrate procedural steps
Item Task Check/initial Comments
Head, face, neck (continued)
Locate and palpate lymph nodes.
Check cranial nerve XI by having patient turn head to each side against resistance and shrug shoulders against resistance.
Eyes Note distribution of eyebrows and eyelashes.
Look for drooping of upper lids or sagging of lower lids.
Note color of sclerae and defects or inflammation of bulbar conjunctivae.
Retract lower lids to note palpebral conjunctivae.
Inspect each iris.
Note size and shape of pupils.
Shine light onto each pupil and note response.
Observe pupils for accommodation.
Check alignment.
Check extraocular movement (six cardinal fields of gaze).
Identify red reflex.
Ears, nose, throat Inspect ears for shape, placement, and discharge.
Check for tenderness by palpating pinna and tragus of each ear and by percussing over mastoid process.
Test hearing.
Use otoscope to inspect ear canals and tympanic membrane.
Check nose for alignment.
Check that septum is midline.
Note any discharge.
Use penlight to check nasal mucosa.
Check patency of nares.
Check cranial nerve I by asking to identify scent.
Assess mouth, lips, oral mucosa, gums, and teeth.
Check tongue, throat, and tonsils.
Test for rising uvula.
Test ability to swallow.
Check for midline tongue protrusion.
Check articulation.
Copyright © 2013 Assessment Technologies Institute®, LLC. All rights reserved. ATITESTING.COM 800.667.7531
ATITESTING.COM 800.667.7531
Demonstrate procedural steps
Item Task Check/initial Comments
Respiratory Count respiratory rate while observing breathing pattern.
Compare inspiratory and expiratory phases of respiration.
Note posture.
Ask about trauma, surgery, and other conditions that affect respiration.
Note use of oxygen.
Inspect thorax for symmetry and configuration.
Note use of accessory muscles.
Check posterior thorax for deformities.
Palpate and percuss over anterior and posterior chest.
Use diaphragm of stethoscope to auscultate over all lung fields.
Check lung expansion.
Cardiac Review vital signs.
Note overall condition (pain, respiratory status, level of consciousness).
Inspect and palpate skin (color, moisture, temperature).
Check color of palpebral conjunctivae.
Palpate carotid arteries for rhythm and rate.
Using bell of stethoscope, listen to carotid arteries for bruits.
Test for jugulovenous distention.
Check for apical pulsation.
Palpate point of maximal impulse.
Auscultate over five cardiac landmarks.
Abdomen Observe contour from two angles.
Note symmetry, color, veins, lesions, scars, hair distribution, umbilicus, and abdominal movement.
Check for inguinal and umbilical hernias.
Auscultate bowel sounds in four quadrants.
Using bell of stethoscope, auscultate abdominal aorta for bruits.
Percuss four abdominal quadrants.
Palpate four abdominal quadrants.
Check for rebound tenderness.
Check for costovertebral-angle tenderness.
Copyright © 2013 Assessment Technologies Institute®, LLC. All rights reserved. ATITESTING.COM 800.667.7531
ATITESTING.COM 800.667.7531
Demonstrate procedural steps
Item Task Check/initial Comments
Musculoskeletal Inspect overall appearance.
Observe gait and balance (tandem, tiptoe, heels).
Perform Romberg test.
Observe spine from lateral and posterior views.
Check spine from lateral view, looking for normal curvatures.
Palpate along spine.
Inspect and palpate skin, joints, and muscle groups of upper and lower extremities.
Test muscle strength of all limbs.
Test range of motion of all limbs.
Check pulses (radial, pedal).
Inspect hair distribution on legs.
Identify presence of edema.
Neurological Evaluate level of consciousness.
Assess orientation.
Assess mood/affect.
Test immediate, recent, and remote memory.
Test motor function and balance together with gait assessment.
Perform Romberg testing.
Test upper-extremity coordination.
Test lower-extremity coordination.
Assess 12 cranial nerves.
Test muscle strength in upper and lower extremities.
Test sensory function: light touch, sharp/dull discrimination, vibration, and monofilament testing on feet.
Test deep tendon reflexes.
Copyright © 2013 Assessment Technologies Institute®, LLC. All rights reserved. ATITESTING.COM 800.667.7531
ATITESTING.COM 800.667.7531
Documentation
Item Task Check/initial Comments
Document per facility policy
Level of consciousness, general survey, vital signs:
Document patient’s level of consciousness and whether or not patient is oriented to person, place, and time.
Describe patient’s general appearance.
Describe patient’s affect, or mood, as well as verbal and nonverbal behavior.
Document temperature, pulse and respiratory rates, blood pressure, and pain level.
Integument:
Note any recent changes in appearance or condition of patient’s skin.
Describe texture of patient’s skin.
Note temperature (warm or cool) of skin and whether it is moist or dry.
Describe skin turgor.
Describe size, shape, and appearance of any moles, lesions, bumps, or wounds.
Document appearance of IV sites.
Head, face, and neck:
Note any pain or tenderness when palpating head, face, and neck.
Describe hair distribution and note any areas of hair loss.
Eyes:
Note position of eyes and color and condition of conjunctivae.
Document PERRLA and EOMs.
Note size, shape, and equality of pupils.
Ears, nose, and throat:
Note position and appearance of ears.
Describe appearance of internal ear.
Note shape, skin color, and alignment of nose.
Describe any inflammation or deformity of nose.
Note any lesions, swelling, bleeding, or drainage.
Inspect mouth and note hydration status.
Note any discoloration of gums or any lesions.
Copyright © 2013 Assessment Technologies Institute®, LLC. All rights reserved. ATITESTING.COM 800.667.7531
ATITESTING.COM 800.667.7531
Documentation
Item Task Check/initial Comments
Document per facility policy
Respiratory:
Document respiratory rate, rhythm, and effort, or work of breathing, oxygen saturation, and oxygen use at time of exam.
Note symmetry, configuration, and any deformities of thorax.
Note any pain or tenderness over thorax.
Document percussion findings and chest expansion.
Describe breath sounds and abnormal sounds.
Document amount, color, consistency, and odor of sputum.
Cardiac:
Document cardiac rate and rhythm.
Document size and location of PMI, if visible, and presence of any lifts, heaves, or thrills with palpation over apex and other precordial landmarks.
Describe heart sounds and any extra sounds such as murmurs, split heart sounds, or friction rubs.
Document whether or not patient has pulse deficit.
Document presence or absence of jugular venous distention.
Note capillary refill.
Document any peripheral edema.
Describe peripheral pulses.
Abdomen:
Note color of skin over abdomen, and any scars, rashes, lesions, or striae.
Describe abdominal contour and symmetry and status of umbilicus.
Document bowel sounds in all quadrants.
Document presence of any bruits.
If you percussed abdomen, document tone generated.
Document palpation findings: whether abdomen is soft, firm, or distended, and any tenderness, rebound or otherwise, and any masses.
Copyright © 2013 Assessment Technologies Institute®, LLC. All rights reserved. ATITESTING.COM 800.667.7531
ATITESTING.COM 800.667.7531
Documentation
Item Task Check/initial Comments
Document per facility policy
Musculoskeletal:
Note ambulation status and any mobility aids.
Describe gait and posture.
Document configuration and range of motion of spine.
Document muscle mass and joint symmetry in upper and lower extremities.
Document muscle strength and joint range of motion.
Note any pain, tenderness, edema, or warmth near joints.
Note amplitude and symmetry of peripheral pulses.
Note results of Romberg testing.
Neurological:
Note level of consciousness and orientation to person, place, and time.
Describe affect, or mood, and memory, if tested.
Document whether or not cranial nerves are intact.
Document gait, balance, and coordination in upper and lower extremities.
Document findings of sensory testing: light touch, sharp/dull discrimination, vibration, and monofilament testing.
Document deep tendon reflexes and Babinski reflex, if done.
Comments
Copyright © 2013 Assessment Technologies Institute®, LLC. All rights reserved. ATITESTING.COM 800.667.7531
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