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PHYSICAL ASSESSMENT DOCUMENTATION

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PHYSICAL ASSESSMENT DOCUMENTATION

PHYSICAL ASSESSMENT DOCUMENTATION GUIDE

    Student____________________________ Date ________________

Client/Patient ___________________________Age ________Sex__________

    General State of Health

    Subjective Data: (Obtain all info under “General State of Health” from Review of Systems page 5 of Jarvis)

Objective Data:

    Appearance

     Posture

     Overall hygiene and grooming

     Any apparent signs of distress

     Dress

    Behavior

     Level of consciousness

    Mood and affect/ Facial expressions (appropriate for situation) Cognition

     Orientation (person, place, time, and purpose-X4)

     Speech (clear, garbled, slurred, incomprehensible)

     Responsiveness (follows directions and responds appropriately)

    Documentations: (Include both Subjective and Objective Data in Narrative Form)

    PHYSICAL ASSESSMENT DOCUMENTATION GUIDE

Student____________________________ Date ________________

Client/Patient ___________________________Age ________Sex__________

    Assessment of the Skin, Hair, and Nails

    Subjective Data: (Obtain all info under “Skin”, “Hair”, & “Nails” from Review of Systems page 5 Jarvis)

Objective Data:

    Inspection and palpation of the skin

     Color(pink, cyanotic, jaundiced, erythematous),

    Pigmentation (even, hyper/hypopigmentation)

     Lesions (Describe 3)

     Description size & color

     Structure - type of lesion (macule, papule, nodule etc.)

     Anatomical Distribution

     Hydration skin turgor (immediate recoil, tenting)

     Temperature & Moisture

    Inspection and palpation of the hair

     Color & condition

     Quantity, distribution, & texture

    Inspection and palpation of the fingernails

     Color of nail bed

     Firmness, texture, ridging, irregularities

     Clubbing:

     Palpate for firm nail matrix

     Estimate nail angle

Documentation: (Include both Subjective and Objective Data in Narrative

    Form)

PHYSICAL ASSESSMENT DOCUMENTATION GUIDE

    Student____________________________ Date ________________

Client/Patient ___________________________Age ________Sex__________

    Assessment of the Head and Neck

    Subjective Data: (Obtain all info under “Head, Eyes, Ears, Nose, Mouth and Neck” from Review of Systems page 5-6 Jarvis)

Objective Data:

    Inspection and palpation of the head and face

     Skull for symmetry & tenderness

     Face (includes eyes, ears, nose, mouth, and neck)

     Symmetry

     Discoloration

     Lesions

     Drainage

     Distention

     Oral mucous membranes color, hydration, lesions

    Documentation: (Include both Subjective and Objective Data in Narrative Form)

PHYSICAL ASSESSMENT DOCUMENTATION GUIDE

    Student____________________________ Date ________________

Client/Patient ___________________________Age ________Sex__________

    Assessment of the Chest and Lungs

    Subjective Data: (Obtain all info under Respiratory from Review of Systems in Jarvis page 6)

Objective Data

    Inspect chest wall

    Color, Configuration (symmetry) and Lesions

    Movement

     Respiratory rate, depth, and effort

    Auscultate systematically for quality of lung sounds

     Assessment of lung sounds and location

    (Clear, diminished, absent)

     Identify adventitious sounds if present:

     Wheezes (sibilant or sonorous rhonchi)

     Crackles (fine or course)

    Documentation: (Include both Subjective and Objective Data in Narrative Form)

PHYSICAL ASSESSMENT DOCUMENTATION GUIDE

    Student____________________________ Date ________________

Client/Patient ___________________________Age ________Sex__________

    Assessment of the Heart and Peripheral Vascular System

Subjective Data: (Obtain all info under Cardiovascular, Peripheral Vascular

    from Review of Systems page 6 Jarvis)

Objective Data

    HEART

    Inspection

     Pulsations, lifts, heaves

     JVD with chest at 35-45 degree angle

    Auscultation

     Rhythm assessment of S1 and S2 (Regular/Irregular)

    Assess all auscultatory sites: APETM

     Count Apical Heart Rate

PERIPHERAL VASCULAR SYSTEM

    Palpation of Peripheral Pulses

     Radial

     Femoral

     Posterior Tibial

     Dorsalis Pedis

    Skin color extremities (upper and lower)

    Capillary refill after blanching (secs)

     Fingers/toes

    Presence of Edema- depress for 5 seconds (grade if pitting)

Documentation: (Include both Subjective and Objective Data in Narrative

    Form)

    PHYSICAL ASSESSMENT DOCUMENTATION GUIDE

Student____________________________ Date ________________

    Client/Patient ___________________________Age ________Sex__________

    Assessment of the Abdomen

Subjective Data: (Obtain all info under Gastronintestinal, Genitourinary

    from Review of Systems page 6-7 Jarvis)

Objective Data

    Inspection

     Contour

     Lesions

     Scars

     Distention

     Pulsations

     Hernia (while patient lifts head)

    Auscultation (all quadrants)

     Bowel sounds

    Palpation

     Light palpation

     Tension of abdominal wall (soft, firm, hard)

     Tenderness

     Masses

     Deep palpation

     Tenderness

     Masses

     Enlarged organs

    Percussion

     CVA tenderness

Documentation: (Include both Subjective and Objective Data in Narrative

    Form)

    PHYSICAL ASSESSMENT DOCUMENTATION GUIDE

Student____________________________ Date ________________

Client/Patient ___________________________Age ________Sex__________

    Assessment of the Musculoskeletal System

    Subjective Data: (Obtain info from Review of Systems under Musculoskeletal in Jarvis)

Objective Data

    Muscle strength

     Check each muscle group against resistance

     Compare right with left:

     Upper extremities

     Triceps

     Biceps

     Adduction arms

     Abduction arms

     Wrists flexion, extension

     Lower extremities

     Quadriceps

     Hamstrings

     Abduction knees

     Adduction knees

     Plantar flexion feet

     Dorsiflexion feet

Documentation: (Include both Subjective and Objective Data in Narrative

    Form)

PHYSICAL ASSESSMENT DOCUMENTATION GUIDE

    Student____________________________ Date ________________

Client/Patient ___________________________Age ________Sex__________

    Neurological Assessment

    Subjective Data: (Obtain info from Review of Systems under Neurological in Jarvis)

Objective Data

    Mental Status Examination

    Appearance (posture, body movement, dress appropriate

    for setting, grooming/hygiene)

    Behavior (level of consciousness, facial expression,

     mood and affect)

    Cognition (orientation x4, responsiveness, speech) Thought Processes (thought content for consistency and logic, perceptions

    consistency with reality, any suicidal thought)

Pupillary Reaction

    (equality, size, shape, reaction to direct and consensual light)

Sensory system

     Spinothalamic tract

     Light touch

     Pain and temperature (only if negative result to light touch)

     Posterior column tract

     Vibration

     Kinesthesia (position sense)

     Stereognosis

     Graphesthesia

     Two-point discrimination

    Motor function

     Hand grips

     Foot pushes

Deep tendon reflexes (Grade)

     Biceps C5-C6

     Triceps C7-C8

     Brachioradialis C5-C6

     Quadriceps L2-L4

     Achilles L5-S1

Cerebellar Functions

     Balance

     Gait

     Gross motor coordination heel to toe walking

     Romberg

    Rapid Alternating Movements (RAM)

Documentation: (Include both Subjective and Objective Data in Narrative

    Form)

PHYSICAL ASSESSMENT PRACTICUM

    Student____________________________ Date ________________

**Starred ** items are critical elements and must be passed by the student.

     Technique Organization Clear Description

     (5) (5) Instructions(2) Accurate (4) General Survey:

     Appearance (posture, grooming, hygiene,

     apparent signs of distress, dress)

     Behavior (attitude, mood and affect, facial expressions)

     Cognition (mental status, speech, level of orientation)

    Skin

     Color (pink, cyanotic, jaundice, dusky, pale)

     Hydration skin turgor

     Temp. and Moisture (warm/cool, dry/clammy)

     Lesions (describes morphology, size, color, pattern of

     Arrangement, and distribution)

    Head and Neck

    Inspection of skull, face (eyes, ears, nose, mouth, , and neck)

    Include oral mucous membranes (moist/dry)

    Assess for drainage, lesions, distention, discoloration, and symmetry Lungs

    Performs inspection before auscultation

    Assess respiratory effort and rate

     Assess for symmetry of chest wall movement

    (chest expansion symmetrical)

     Auscultate for breath sounds (anterior or posterior chest)

     in a systematic order

    Heart

    Identify auscultatory sites: nd Aortic 2 right ICS ndPulmonic 2 left ICS thTricuspic Left 5 ICS sternal border or midsternal line th Mitral left 5 ICS midclavicular line

    **Auscultate S1 and S2 - assess rhythm (S1 S2 Reg./irreg.)

     assess for extra heart sounds & murmurs thIdentify PMI (left 5 ICS midclavicular line)

    Count Apical heart rate (BPM)

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