#1 EQUIPMENT

EQUIPMENT
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Clean Hands
Stethoscope
Penlight
Ophthalmoscope/Otoscope
Near Vision Card/ Snellen Eye Chart
Tongue Blade
Gloves
Cotton Balls/Cotton Tipped Applicator
Cup of Water
Lemon Juice, Sugar, Salt

TECHNIQUES OF PHYSICAL
ASSESSMENT

Inspection
Palpation
Percussion
Auscultation

#2 GENERAL
SURVEY

GENERAL SURVEY
 Visible skin
 Facial expression/Mood (Grimace, Flat
Affect, Pleasant, Distress, SOB)
 Nutritional Status (Cachexia, Obesity,
Well-nourished)
 Grooming/Hygiene (UnKempt, Neat,
Poor Hygiene)
 Gross Anatomical Deformities

EXAMPLES

#3 SKIN

SKIN
• Integument
• Color
Pigmentation
Cyanosis
Jaundice
Erythema

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Moisture
Temperature
Texture
Turgor

SKIN (CONT’D)
Vascularity
Edema
Lesions

ABCD:
 Asymmetry
 Border irregularity
 Color
 Diameter

HAIR AND SCALP
Hair:
Color
Distribution
Quantity
Thickness
Texture
Lubrication

NAILS
Condition of nails reflects: General health
State of nutrition
Occupation
Level of self-care
Age

#4 NEUROLOGICAL
SYSTEM

““

SMILE FOR ME”

NEUROLOGICAL ASSESSMENT

 Orientation (person, place, time, purpose)  12 Cranial Nerves/Sensation
 Glascow Coma Scale

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12 CRANIAL NERVES

Olfactory
Optic
Oculomotor
Trochlear
Trigeminal
Abducens
Facial
Auditory
Glossopharngeal
Vagus
Spinal Accessory
Hypoglossal

#5
HEAD & NECK

COMPONENTS OF HEAD &
NECK
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Ears
Nose
Eyes
Throat
Neck
Lymph Nodes

EYES
Inspect
• Anterior Eyes
• Eyelashes
• Conjunctivae
• Tear Ducts

EYE EXAMINATION
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CN’s II, III, IV,& VI
Six Cardinal Fields of Gaze
Visual Acuity
Cover-Uncover Test
PERRLA
Peripheral Vision
Ophthalmic Exam

OPHTHALMIC EXAMINATION

Things to know for NCLEX:

EARS
Assess Outer Ear for:
• Drainage
• Foreign Bodies
• Lesions
• Erythema
• Pain/Tenderness
• Cerumen

EAR EXAMINATION
Tests:
• Weber
• Rinne
• Otoscopic Examination

NOSE AND SINUSES
Nose
Excoriation
Polyps
Sinuses

MOUTH AND PHARYNX
Lips
Color
Texture
Hydration
Contour
Lesions

MOUTH AND PHARYNX (CONT’D)
Buccal mucosa
Gums
Teeth

MOUTH AND PHARYNX (CONT’D)
Tongue
Floor of mouth

MOUTH AND PHARYNX (CONT’D)
Palate
 Hard
 Soft

Pharynx

TONSILS

LYMPH NODES & THYROID

RESPIRATORY SYSTEM

THORAX AND LUNGS
Examination

Inspection (symmetry)
Palpation (Tenderness)
Percussion (Resonance)
Auscultation

THORAX AND LUNGS (CONT’D)
Auscultation

Adventitious sounds Crackles
Rhonchi
Wheezes
Pleural
friction rub

BREATH SOUNDS VIDEO

STRIDOR

PLEURAL FRICTION RUB

CARDIOVASCULAR SYSTEM

CARDIOVASCULAR SYSTEM
Assess the following items:
• Inspect for abnormal pulsations over the heart/abdominal aorta
• Jugular Vein Distension (JVD)
• Heart Sounds (S1 & S2)
• Pulses
• Capillary Refill
• Hair Distribution (on extremities)

VASCULAR SYSTEM
Pulses
0: absent, not palpable
1+: pulse diminished, barely palpable
2+: expected/normal
3+: full pulse, increased
4+: bounding pulse

HEART SOUNDS
Normal Findings
S1 and S2
Abnormal Findings
S3, S4, Murmurs, Clicks, Heaves, Bruits
* Using your stethoscope: use the diaphragm to assess for S1, S2 heart sounds and bell to assess vascular sounds (Bruits etc)

AUSCULTATION OF THE HEART

AUSCULTATION OF HEART
SOUNDS

ABDOMEN

ABDOMEN
Inspection
Umbilicus
Contour and symmetry
Enlarged organs or masses
Movements or pulsations

ABDOMEN
Auscultation
Bowel motility (Bowel Sounds)
Peristalsis
Borborygymi
Vascular sounds (use the bell)
Bruits
Kidney tenderness (CVA Tenderness in Flank)

PERCUSSION
Used to determine the following thing:
• General Tympany
• Location/size of liver and spleen
• Presence of masses

ABDOMEN
Palpation
 Performed last
 Detects tenderness, distention, or masses  May be light or deep, as appropriate
 Aortic pulsation

BREASTS & THE REPRODUCTIVE
SYSTEMS

BREASTS
Examine both females and males.
Use inspection and palpation.
Look for symmetry.

BREAST SELF-EXAMINATION
(CONT’D)
6. Repeat steps 4 and 5 while lying down. Lie flat on back, right arm over head and pillow/folded towel under right shoulder. This position flattens the breast for easier examination. Use same circular motion described earlier.
7. Repeat on the right breast.

BREASTS

FEMALE GENITALIA
AND REPRODUCTIVE TRACT
Pelvic Examination (Pap
Smear)
• Recommended every 1-2 years • Tests cervical tissue
• Done via bimanual method • Position is lithotomy

MALE GENITALIA
• Assess the integrity of the external genitalia, inguinal ring, and canal.
• Use inspection and palpation. • Assess testes, penis, and scrotum
• Age 35-40 prostate exam MUSCULOSKELETAL SYSTEM

COMPONENTS
The musculoskeletal system includes:
• Joints
• Motor Function
• Gait/Posture
• Spine
• Range of Motion of all joints
• Muscle Strength
• Deep Tendon Reflexes

MUSCULOSKELETAL SYSTEM
General inspection:
Gait
Postural abnormalities Age-related changes

MUSCULOSKELETAL SYSTEM
Assess for lordosis, kyphosis, or scoliosis.

MUSCULOSKELETAL SYSTEM
Palpation
Joints
Bones
Muscles
Grading Muscle Strength and Deep Tendon
Reflexes
 Muscle Strength Scale: 0-5 ; normal is 5
DTR’s: 0-4+ ; normal is 2

MUSCULOSKELETAL SYSTEM
(CONT’D)
Range of motion
Active and passive

DEEP TENDON REFLEXES
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Biceps
Triceps
Patellar
Achilles
Plantar
Abdominal

AFTER THE EXAMINATION
Record findings.
Give the patient time to dress; assist if needed.
If findings are serious, consult health care provider before informing the patient.
Delegate cleaning of examination area.
Record complete assessment; review for accuracy and thoroughness.
Communicate significant findings.