Physical_Exam_Format_NURS_680__Student_Copy__1_.pdf (2)

Professional Patient Interaction  Approach to client is professional  Introduce yourself as a Registered Nurse and a Student Nurse Practitioner  Responds appropriately to client verbally and non-verbally  Maintains client privacy during exam  Client is appropriately draped during the entire exam  Washes hands before examination begins Exam is done in while client is seated General Survey  Inspect for development, nutrition/hydration status/ grooming  Observe gait during, before or after the exam  Inspect skin over entire body throughout the exam. State color and presence of lesions or other anomalies if noted Head  Inspects and palpates the head and scalp  Notes hair distribution Eyes  Inspects eyes for alignment and symmetry  Describe external eye structures  Assess visual acuity before shining light into eyes (Snellen hand held- both eyes)  Check visual fields checking upper, lower, medial and lateral fields of both eyes (Test: Confrontation or Static Finger Wiggle Test)  Test extra ocular movements (Letter H format)  Check for direct and consensual pupillary response to light  Check for Accommodation  Perform ophthalmoscopy examination o Hold and adjust scope appropriately o Test for red reflex or elicits the red flex o Describes internal eye structures (optic disc, arterioles and veins and macula) Ears  Inspects external ear structures  Evaluates auditory acuity (whisper test)  Perform Rinne’s test (tuning fork)  Perform the Weber’s test (tuning fork)  Perform otoscopic exam o Holds and adjusts scope appropriately o Holds scope in such a way that the TM is protected from rupture if the client should move head suddenly o Properly manipulates head, otoscope and ear canal without causing pain Nose  Inspect the nose using a speculum. Describe mucosa, septum & turbinates. This study source was downloaded by from CourseH on :39:11 GMT -05:00  Palpate sinuses  Check that smell is intact using strong scent like coffee (not required for examination) Mouth  Use tongue blade to inspect the mouth. Describe lips, buccal mucosa, sublingual area, gums, teeth.  Use tongue blade to inspect posterior pharynx  Describe posterior pharynx & grade tonsils Neck  Evaluates mobility of neck / ROM  Palpates lymph nodes of neck, states names of cervical lymph node chains & describes. o DOES NOT massage carotid sinuses o Inspects anterior chain unilaterally  Inspects and palpates thyroid gland using posterior approach, having the client swallow o DOES NOT massage carotid sinuses Posterior Chest Back  Inspect back and describe any abn