Physical Assessment Help!

OB-nurse2013, BSN, RN · Sep 21, 2011

I'm not sure how your school is but for us they want you to basically go from head to toe. So when I validated for that I would say that I was noticeing gait, orientation as they were walking in and just responding to me and making eye contact and then I just did the assess. starting with everything at the head and then go down from there.

NurseMaybeBaby · Sep 22, 2011

Pretty much what PP said. I start with AAO, check eyes and mouth. Then I move to heart sounds and lung sounds. Palpate radial pulses and check capillary refills. Then ROM with arms. Then bowel sounds and palpate abdomen. Then I move on to the legs and do ROM, check for edema and capillary refills. Then I end with pedal pulses.

Your school may differ on exactly what they want done. This follows the post-clinical paperwork we fill out each week. I'm in second semester, first clinical. Not sure how it will change as we progress.

This is also basically what we did during the assessment course last semester. It gets easier after doing it a bajillion times!

santina44 · Sep 24, 2011

It sounds obvious, but just perform it in a head to toe fashion. Use the body as your cue.

I start with AAOX3. Usually you don't need to say anything if a teacher is watching because they can hear the pts response. Then, I go on to my cranial nerves-- checking eye movements, hearing, etc. I narrate aloud what I am doing, which nerve I am checking. Some teachers are not picky and don't make you name each nerve, luckily.

Do you have someone you can practice on? While you're doing it, just explain to them everything you are doing and why as if you were talking to the teacher.

dmw2489 · Sep 24, 2011

Hello, our school isnt picky on how you get the assessment done as long as you get all the information, i seem to do this a different way then head to toe, for example i am on a respiratory unit in clinicals for this rotation so,

the first thing i do is do a visual scan of everything in the room, bed position, O2, IV, do they have glassess or dentures on their side table? then as i am doing the visual scan i introduce myself, take vitals and check orientation i ask them to tell me their name, if they know where they are, what time/date/or month it is, and if they know why they are here.

then being on respiratory i check their lung sounds at the front, from there since my stethoscope is already on their chest i then check apical and heart sounds. right after i then check bowel sounds and THEN palpate abdomen.

from there i move to feet to check pedal pulses & cap refill, while doing that ask them questions, (are you having any trouble breathing? do you have any pain? how did you sleep last night? do you have any dizziness/lightheadedness?) then i check holmans sign and if negative ask them if they can lift their right leg and then left.

Then move to upper extremeties and do the same thing as with lower. here i will also ask them to move their shoulders to their ears and squeeze my hands.

Then from there I check their mucous membranes, perrla, conjuctiva, palpate lymph nodes around ears and down neck.

Then just do another visual scan to see if there was anything i missed or i needed to fix.

Your assessment may end up changing depending on your patient or patients problem or deficit. That is the one thing I have learned is you may have to adjust your assessment to pts needs so never rely on being able to go head to toe or even being able to do a full assessment all at once (i had a pt that needed frequent rests, so my assessment had to be broken down into 3 different parts)

I hope this helped and i hope i did not miss anything either lol good luck :)