Health Assessment Nursing BSN

NUR 378: Physical Examination Demonstration Checklist/Rubric

System Points Student’s Points 1. General Survey: comment on your observations: posture, gait, grooming, affect, eye contact

1 ½

2. Head _____ Head: size, shape _____ Face: symmetrical features _____ Hair: texture, distribution _____ Scalp: examine for lesions _____ Eyebrows: thinning at lateral borders Skin (comment on visible skin, comment on skin throughout exam) _____ Color, texture, moisture, temperature _____ Lesions: presence, absence. If present, describe characteristics, distribution

_____ Nails _____ Organization, techniques, verbalizes findings correctly

¼ ¼ ¼ ¼ ¼ 1 1 ¼ 1 (4.5)

4. Eye ______Inspection

Palpebral fissure Lacrimal ducts Lids: lashes, lesions, ptosis, infestations Conjunctiva: pale, injected Sclera: presence, absence icterus

Cornea: clear, scarred, lesions, arcus Iris: uniform color, size

______Pupil Inspection Size,

Shape Regularity Equality

______Pupillary Response: direct & consensual reaction to light, near reaction CN 3 ______Cardinal fields of gaze: eyes move together. CN 3,4,6 Comment on EOMS, nystagmus

______Visual Acuity: hand held Snellen chart CN2 ______Organization, techniques, verbalizes findings correctly

1½ 1½ 1 ½ 1 1 (6.5)

5. Ears ______ Auricles: Inspect anterior _____ posterior____ ______ Palpate external ear and mastoid for tenderness ______ External canal: inspect for lesions, drainage ______ Tympanic membrane: inspect, comment on landmarks, cone of light ______ Hearing: test with whispered voice or watch tick CN 8 ______ Organization, techniques, verbalizes findings correctly

¼ ¼ ½ 1½ ½ 1 (4)

6. Nose and Sinuses ______External structures: skeleton: inspect, palpate ______Internal Structures Septum: inspect for deviation, perforation, lesions

Mucosa: inspect for color, lesions ______ Sinuses: frontal, maxillary, palpate for tenderness ______ Organization, techniques, verbalizes findings correctly

½ ½ ½ ½ (2)

NUR 378: Physical Examination Demonstration Checklist/Rubric

7. Mouth & Pharynx

______ Lips: inspect for lesions, dryness ______ Buccal mucosa, teeth, gums: inspect for lesions, caries, repairs, absent teeth, condition of gums ______ Tongue: inspect for coating, papillation, lesions Tongue protrudes midline CN 12 ______ Sublingual area: inspect for lesions, saliva ______ Hard palate, uvula & soft palate: inspect for lesions.

Inspect for uvula to rise in midline CN 9, 10 ______ Tonsils: inspect for presence/absence, size, erythema, swelling, exudates ______ Posterior pharynx: inspect for erythema, exudates, lesions ______ Organization, techniques, verbalizes findings correctly

¼ ¼ ¼ ½ ½ ½ ½ 1 (4.25)

8. Nodes ______ Preauricular, postauricular ______ Submandibular, submental, tonsillar ______ Superficial cervical, deep cervical, posterior cervical, occipital ______ Supraclavicular, infraclavicular ______ Axillary: central, lateral, anterior, posterior , epitrochlear ______ Inguinal- can include with abdominal exam when partner lying down ______ Organization, techniques, verbalizes findings correctly

½ ½ ½ ½ ½ ½ 1 (4)

9. Neck ______ Trachea: inspect and palpate that it is in midline ______ Thyroid: inspect for enlargement. Palpate for enlargement, masses, tenderness ______ Carotids: palpate for strength of pulsation. Auscultate for bruits ______ Organization, techniques, verbalizes findings correctly

½ ½ ½ ½ (2)

10. Thorax and Lungs

______ Inspection: AP to lateral diameter: comment on ratio Respiratory effort, use of accessory muscles

______ Palpate posterior chest: describe tactile fremitus and chest expansion ______ Percuss: lung fields, posterior chest ______Auscultate: breath sounds anterior, posterior, describe breath sounds heard adventitious sounds: absent/present ______Organization, techniques, verbalizes findings correctly

2 1 2 2 2 (9)

11. Heart and Neck Vessels ______Inspection: heaves, lifts _______Palpation: thrills ______ Palpation: apical impulse: location, amplitude, rhythm _______Auscultation Identify landmarks and auscultate w diaphragm Aortic area Pulmonic area Tricuspid area Mitral area

½ ½ 5 ½ ½ ½ ½ ½

NUR 378: Physical Examination Demonstration Checklist/Rubric

Left lateral w/ bell to accentuate S3, S4, mitral murmur Supine right sternal border w/ bell Sit up, exhale, lean forward, diaphragm in left sternal border to accentuate aortic insufficiency ______Organization, techniques, verbalizes findings correctly

½ 2 (11)

12. Peripheral Vascular: palpate and comment: pulses present/absent; pulse strength from 1-2+

______ Temporal ______ Radial ______ Brachial ______ Femoral ______ Popliteal ______ Posterior tibial ______ Dorsalis pedis ______ Lower extremities inspect for leg varicosities ______ Lower extremities inspect, palpate for edema ______ Organization, techniques, verbalizes findings correctly

½ ½ ½ ½ ½ ½ ½ ½ ½ 1 ½ (6)

13. Abdomen

______ Inspect: contour, masses, scars, skin ______ Auscultate: bowel sounds in 4 quadrants ______ Auscultate for renal bruits, femoral bruits ______ Percuss: identify sounds ______ Light palpation 4 quadrants and flanks: tenderness, masses ______ Deep palpation 4 quadrants and flanks: tenderness, masses ______ Palpate for liver’s edge ______ Palpate for spleen tip

______ Demonstrate technique for rebound tenderness ______ Liver span percussion and measurement ______ Demonstrate assessment for CVA tenderness ______ Organization, techniques, verbalizes findings correctly

1 1 1 1 1 1 1 1 1 1 1 2 (13)

14. Musculoskeletal: Demonstrate inspection, palpation, range of motion: ______ Temporal-mandibular (TM) joint ______ Neck: flexion, extension, lateral bending, rotation ______ Shoulder: abduction, adduction, internal & external rotation, flexion, extension ______ Elbow: flexion, extension, supination, pronation ______ Wrist: flexion, extension, radial deviation, ulnar deviation ______ Fingers: flexion, extension, abduction, adduction ______ Knee: flexion, extension ______ Ankle: flexion, extension, inversion, eversion ______ Toes: flexion, extension, abduction, adduction ______ Hips: abduction, adduction, internal & external rotation, flexion. ______ Spine: flexion, extension, lateral bending, rotation

______Organization, techniques, verbalizes findings correctly

½ ½ ½ ½ ½ ½ ½ ½ ½ ½ ½ 2 (7.5)

NUR 378: Physical Examination Demonstration Checklist/Rubric

15. Neurological Mental Status: ______ Level of consciousness, ______ Orientation (x3) ______ Cognitive function: test memory ______Higher intellectual function ______ Judgment ______ Organization, technique, verbalizes findings correctly Cranial Nerves: ______ 1 Olfactory: smell ______ 2 Optic: visual acuity ______ 3,4,6 Pupil response direct, consensual ______ Cardinal fields of gaze: describe positive, negative findings ______ 5 Trigeminal sensory: light touch, pain to 3 dermatomes Trigeminal motor: muscle strength clenched jaw ______ 7 Facial motor: frown, smile & show teeth, wrinkle forehead ______ 8 Acoustic: whispered voice ______ 9&10 Glossopharangeal & vagus

Motor: symmetrical rising of soft palate, uvula ______11 Spinal accessory motor: turn head, shrug against resistance ______12 Hypoglossal motor: tongue protrudes in midline ______ Organization, techniques, verbalizes findings correctly Motor: ______ Inspect muscle bulk, tone. Comment on any unusual movements, tremors, Test muscle strength against resistance in major muscle groups. Grade strength 0-5 ______ Upper extremities ______lower extremities Test coordination - demonstrate either rapid alternating movements or point-to-point ______ Upper extremities ______lower extremities ______ Organization, techniques, verbalizes findings correctly (** Cerebellar function is part of the motor system but test last since it requires patient to stand) Sensory: Cover major dermatomes in arms, legs ______ Light touch (cotton) * Avoid “dull” it is not part of the test, just a distractor ______ Pain (broken tongue blade, paper clip) ______ Vibratory sense with 128 Hz tuning fork ______ Position sense great toe and index finger bilaterally ______ Organization, techniques, verbalizes findings correctly Deep Tendon Reflexes Grade as 1-4 ______ Triceps, biceps, brachioradialis, knee, ankle. ______ Plantar response. Comment on normal ______ Organization, techniques, verbalizes findings correctly Cerebellar Function: Equilibrium & Gait ______ Gait – comment that you observed this upon patient’s entering room ______ Heel to toe walking ______ Romberg: feet together, eyes closed. Comment usually allow 20-30 seconds,

no sway negative. ______ Pronator drift: Comment that pronation & drift is abnormal (** Combine Romberg and pronator drift to save time.) ______ Organization, techniques, verbalizes findings correctly

1 ¾ 1 ½ ½ ½ ½ ½ ½ ½ ½ ½ 1 1 1 1 1 1 1 1 1 1 3 ½ 1 ½ ½ ½ ½ 1 (24.75)

NUR 378: Physical Examination Demonstration Checklist/Rubric

TOTAL SCORE 100 Points

GRADING CRITERIA

1. There are a total of 100 points. Passing grade is 73.

2. Additional points will be deducted if the exam is performed in a disorganized, unprofessional manner.