Nursing 6830 Comprehensive Physical Examination Template

Nursing 6830 Comprehensive Physical Examination Template

STUDENTS MAY USE THIS AS A TEMPLATE FOR THEIR WRITE-UP

Otterbein University Graduate Studies in Nursing

Nursing 6830 –Spring 2021

(Appendix E-3 Below E with RUBRIC APPENDIX)

Comprehensive Physical Examination

1. General appearance

Include general state of health, build, and sexual development. Note posture, motor activity, and gait; dress, grooming, and personal hygiene; and any odors of body or breath. Note manner, affect, and reactions to people and environment, speech. Note state of awareness or level of consciousness.

1. Measurement

Ht, Wt, BP, P, R, BMI

 

1. Skin

– Inspect skin, hair, nails

 

1. Head & face

– Inspect  hair, scalp, skull and face

 

1. Eye

– Check visual acuity and screen visual fields

– Note position and alignment of eyes

– Observe eyelids and inspect the sclera and conjunctiva of each eye

– Inspect cornea, iris and lens

–  Extraocular muscles movement

– Pupil, size, response to light/accommodation

– Opthalmoscopic exam:  red reflex, disc, vessels, retinal background

1. Ear

– Inspect auricles, canals and drum (otoscope for canals and drum)

– Check acuity. If acuity diminished, check Weber and Rinne.

1. Nose

– Inspect external nose – symmetry

– with nasal speculum, inspect  mucosa, septum, turbinates

– palpate for tenderness of frontal and maxillary sinuses

1. Mouth & throat

– Inspect lips, oral mucosa, gums, teeth,  tongue, palate, tonsils and pharynx

– Note mobility of uvula as person says aaaaah

1. Neck

– Inspect and palpate the cervical lymph nodes: note masses or pulsations

– Feel for deviation of trachea

– Inspect and palpate thyroid

1. Back

-Inspect and palpate the spine and muscles of the back.

-Observe shoulder height for symmetry

1. Posterior Thorax and Lungs

– Inspect posterior chest: skin, thorax, symmetry, movement

– Palpate: symmetrical expansion, tactile fremitus

– Percuss: lung fields, diaphragmatic excursion

–  Auscultate:  breath sounds (normal vs. adventitious); transmitted voice sounds if indicated

1. Breasts, Axillae, and Epitrochlear Nodes

-In a woman, inspect breast with arms relaxed, then elevated, and then with hands on hips

-Inspect axillae and feel for axillary nodes. Feel for epitrochlear nodes.

-Palpate breasts (may be deferred or may do over t-shirt or gown)

1. Upper Extremities

-Examine hands, arms, shoulders, neck and temporomandibular joints

-Inspect and palpate joints and check their range of motion

-Examine upper extremity muscle bulk, tone, strength, and reflexes

-Check radial and brachial pulses

 

1. Anterior Thorax

– Inspect: skin, thorax, symmetry, movement

–  Palpate:  expansion, tactile fremitus

–  Percuss:  lung fields

–  Auscultate breath sounds, transmitted voice sounds

1. Cardiovascular System

– Observe for jugular venous pulsations and measure the JVP

– Inspect and palpate carotid pulsations. Listen for carotid bruits

– Inspect and palpate precordium for pulsations, heaves

– Note the location, diameter, amplitude and duration of apical pulse

– Listen at each auscultatory area with the diaphragm of the stethoscope

– Listen at the apex and the lower sternal border with the bell

–  Turn person to left side while auscultating apex with bell

– Have patient sit, lean forward, and exhale while you listen at the base

1. Abdomen

– Inspect: contour, symmetry, skin characteristics, umbilicus & pulsations

– Auscultate bowel sounds, aortic bruits, renal artery bruits

– Percuss abdomen. Palpate abdomen lightly, then deeply.

– Assess the liver and spleen by percussion and then palpation

– Try to feel the kidneys, and palpate aorta and its pulsations

– Percuss posteriorly over the costovertebral angles if indicated

1. Lower extremities (While supine)

– Palpate femoral, popliteal, dorsalis pedis, posterior tibial pulses

– Palpate the inguinal lymph nodes.

– Inspect for lower extremity edema, discoloration, or ulcers. Palpate for pitting edema.

– Inspect joints, palpate joints, check range of motion

– Assess lower extremity muscle bulk, tone and strength, assess sensation and reflexes

– Inspect & separate toes

(Standing)

-Inspect for varicose veins

-Examine the alignment of the spine and its range of motion, the alignment of legs and feet

– Genitalia and hernia in men – defer this exam

-Observe patient’s gait and ability to walk heel-to-toe, toe walk, heel walk, hop, shallow knee bends. Romberg test and check for pronator drift

1. Nervous System

– Test mental status – orientation, mood, thought process, thought content, abnormal perceptions, insight and judgment

– Test cranial nerves – (In addition to what was done in HEENT exam) check smell, strength of temporal and masseter muscles, facial movement, gag reflex and strength of trapezia and sternomastoid muscles.

– Test motor system – Cerebellar function – Rapid alternating movements, point to point movements

– Test sensory ability – pain, light touch, vibration

– Reflexes – Check deep tendon reflexes: biceps, triceps, brachioradialis, patellar, ankle, Babinski

Problem List (indicate any problems found in history or on exam)

Risk Profile (indicate risk factors that may lead to future problems)

Appendix E-3: Final Physical Exam Write Up – Grading Rubric 20 points

	Partial Points	Partial Points	Full Points
Clear	Descriptions consistently not clear and appropriate terminology not used (1-2)	Descriptions not always clear or appropriate terminology not used (2-3)	Descriptions are clear and appropriate terminology is used (4)
Uses concise descriptions	Either missing several descriptive elements or is overly wordy (1-2)	Either missing descriptive elements or is overly wordy (3)	Descriptions are not overly wordy, and do not omit essential parts (4)
Accurate	Write up differs from exam performed in more than one way (1-2)	Write up differs from exam performed in one way (3)	Write up accurately reflects the physical exam performed (4)
Appropriate	Does not include more than one  component that should be performed based on the history or a comprehensive exam (1-2)	Does not include a component that should be performed based on the history or a comprehensive exam (3)	The exam is appropriate for a comprehensive physical exam and the patient’s history (4)
Problem List	Problem list updated but more than one problem from physical exam findings is missing (1-2)	Problem list updated but at least one problem from physical exam findings is missing (3)	Problem List updated to reflect physical exam findings (4)