Physical Assessment Guide
Basic Screening Physical Examination for Adults
❑ Complete
Greeting/Introduction: ❑ Not Complete
❑ Follow Up
❑ Introduce yourself; provide your name, purpose, and length of time you will be with your
patient. Do not address your pt. by name at this point!
o “Good morning, I’m Cheryl; I will be your student nurse today. I’m here
until 3:00pm working with your nurse Phil. May I do a morning
assessment, it will take about 10 minutes.” (not necessarily a question)
❑ Wash your hands, check patient I.D. band, and have pt. state their name and birth date
❑ Provide for privacy, comfort, and dignity!
❑ Establish working relationship built on trust and mutual respect
❑ Complete
❑ Not Complete
Environmental Check: ❑ Follow Up
❑ Call light working and within pt. reach, bed locked and in low position, side rails up/down,
working suction when appropriate, items needed within comfortable/safe reach such as
water pitcher, glasses, dentures, hearing aids, TV controls, phone, urinal, trash
receptacle available and within easy reach
❑ Check for obstacles/clutter at bedside or route to bathroom and/or sink
❑ Medical supplies and equipment, i.e. O2 tubing and set-up, I.V. lines and machinery
functioning/appropriate rate, feeding/abd. tubes and lines, chest tubes, tracheostomy
supplies including emergency obturator, Foley catheter, ambulation assistive devices
❑ Tubes and Lines – follow each line from patient to device, look at connections, amount of
room to move, secured in place, and labels
❑ Any surgical supplies and equipment; dressing supplies, CPM, traction, abd. pillow,
Incentive Spirometer (IS),!!!
❑ Updated information on whiteboard in pt. room w/ name of nurse, doctor, nurse aid, etc.
❑ Emotional/Family support, i.e. is family/a visitor present or any visual cues of personal
support such as cards, flowers, pictures, etc.
❑ Begin assessment with emphasis on accuracy, flow, and patient comfort. Get a complete
set of vital signs if not already done. Begin assessment on system of greatest concern.
General Appearance/Psychosocial: ❑ Complete
❑ Not Complete
❑ Follow Up
❑ Acute distress or pain or any immediate needs?
❑ Does the patient acknowledge your presence?
❑ Overall affect- normal, flat, depressed, anxious?
❑ General mood- happy, cooperative, depressed (Even though this is not an
appearance, this is a first impression aspect of your assessment)
❑ Any communication barriers?
❑ Inspect for development, nutrition/hydration status/ grooming
o “Patient is well-developed, well-nourished, and well-groomed….”
❑ Observe gait during, before or after the exam
o “Gait steady when ambulated from to at 0930”
❑ Inspect skin over entire body throughout the exam
❑ State color and presence of lesions or other anomalies
o “Skin appears pink, well-hydrated, with no obvious or reported lesions.”
❑ Inspect upper & lower extremities, including nails
, o “Extremities warm without edema.”
o “Nail beds appear pink without lines, ridges, clubbing, or cyanosis.”
❑ Palpate radial pulses, check for cap. refill to finger tips/nail beds
o “Radial pulses are 2+ with brisk cap refill”
❑ Check surgical site, any wounds or skin lesions. Consider size, location,
drains, dressings present and intactness, any surgical supplies required
❑ Complete
❑ Not Complete
Head/Neck: ❑ Follow Up
❑ Inspect and Palpate the head and scalp ( in an acute setting, palpate PRN
only)
o “Head is normocephalic with no scars, masses, lesions, or
tenderness. Good hair distribution and of average texture”
❑ CN 5 (Trigeminal)-Ask patient to blink eyes, open mouth, and clench teeth.
Palpate the temporal and masseter muscles as they clench.
❑ CN 7 (Facial)-Look at facial asymmetry. Ask patient to wrinkle forehead, shut
eyes tightly, grin, frown, shows teeth, and puff out cheeks.
❑ Note any lesions, deformities, dressings, size and shape
❑ Hair; evenly distributed, color, texture, balding patterns
❑ Mini mental exam: LOC and orientation to person, place, time, purpose
❑ Evaluate mobility/ROM of neck
o CN 11 (Accessory)-From behind; examine for shoulder asymmetry,
shrug shoulders, turns head against resistance
❑ Inspect Neck
o “Neck supple. Trachea midline. No neck masses.”
❑ Verbally address any issues related to this body system
❑ Complete
❑ Not Complete
Eyes: ❑ Follow Up
❑ Inspect eyes for alignment and symmetry
o “Eyes are symmetrical with good alignment.”
❑ Describe external eye structures
o “No abnormalities of the eye lids. Conjunctiva is pink. Sclera is white.
No excessive tearing or discharge.”
❑ Test extra ocular movements
o CN 6: Perform H pattern 15-18 inches from the patient nose. Finish
with convergence (AKA: 6 cardinal fields of gaze)
o CN 3, 4, and 6 (Oculomotor, Trochlear, Abducens) - PERRLA, direct
and consensual responses, ROMs using “H” pattern, convergence,
accommodation.
❑ “Extraocular movements for cranial nerves 3, 4, and 6
intact.”
❑ Check for papillary response to light, and accommodation.
o “Pupils 4mm constricting to 2mm, round regular, equally reactive to
light. Pupils accommodate to near and far vision.”
❑ Verbally address any issues related to this body system
Basic Screening Physical Examination for Adults
❑ Complete
Greeting/Introduction: ❑ Not Complete
❑ Follow Up
❑ Introduce yourself; provide your name, purpose, and length of time you will be with your
patient. Do not address your pt. by name at this point!
o “Good morning, I’m Cheryl; I will be your student nurse today. I’m here
until 3:00pm working with your nurse Phil. May I do a morning
assessment, it will take about 10 minutes.” (not necessarily a question)
❑ Wash your hands, check patient I.D. band, and have pt. state their name and birth date
❑ Provide for privacy, comfort, and dignity!
❑ Establish working relationship built on trust and mutual respect
❑ Complete
❑ Not Complete
Environmental Check: ❑ Follow Up
❑ Call light working and within pt. reach, bed locked and in low position, side rails up/down,
working suction when appropriate, items needed within comfortable/safe reach such as
water pitcher, glasses, dentures, hearing aids, TV controls, phone, urinal, trash
receptacle available and within easy reach
❑ Check for obstacles/clutter at bedside or route to bathroom and/or sink
❑ Medical supplies and equipment, i.e. O2 tubing and set-up, I.V. lines and machinery
functioning/appropriate rate, feeding/abd. tubes and lines, chest tubes, tracheostomy
supplies including emergency obturator, Foley catheter, ambulation assistive devices
❑ Tubes and Lines – follow each line from patient to device, look at connections, amount of
room to move, secured in place, and labels
❑ Any surgical supplies and equipment; dressing supplies, CPM, traction, abd. pillow,
Incentive Spirometer (IS),!!!
❑ Updated information on whiteboard in pt. room w/ name of nurse, doctor, nurse aid, etc.
❑ Emotional/Family support, i.e. is family/a visitor present or any visual cues of personal
support such as cards, flowers, pictures, etc.
❑ Begin assessment with emphasis on accuracy, flow, and patient comfort. Get a complete
set of vital signs if not already done. Begin assessment on system of greatest concern.
General Appearance/Psychosocial: ❑ Complete
❑ Not Complete
❑ Follow Up
❑ Acute distress or pain or any immediate needs?
❑ Does the patient acknowledge your presence?
❑ Overall affect- normal, flat, depressed, anxious?
❑ General mood- happy, cooperative, depressed (Even though this is not an
appearance, this is a first impression aspect of your assessment)
❑ Any communication barriers?
❑ Inspect for development, nutrition/hydration status/ grooming
o “Patient is well-developed, well-nourished, and well-groomed….”
❑ Observe gait during, before or after the exam
o “Gait steady when ambulated from to at 0930”
❑ Inspect skin over entire body throughout the exam
❑ State color and presence of lesions or other anomalies
o “Skin appears pink, well-hydrated, with no obvious or reported lesions.”
❑ Inspect upper & lower extremities, including nails
, o “Extremities warm without edema.”
o “Nail beds appear pink without lines, ridges, clubbing, or cyanosis.”
❑ Palpate radial pulses, check for cap. refill to finger tips/nail beds
o “Radial pulses are 2+ with brisk cap refill”
❑ Check surgical site, any wounds or skin lesions. Consider size, location,
drains, dressings present and intactness, any surgical supplies required
❑ Complete
❑ Not Complete
Head/Neck: ❑ Follow Up
❑ Inspect and Palpate the head and scalp ( in an acute setting, palpate PRN
only)
o “Head is normocephalic with no scars, masses, lesions, or
tenderness. Good hair distribution and of average texture”
❑ CN 5 (Trigeminal)-Ask patient to blink eyes, open mouth, and clench teeth.
Palpate the temporal and masseter muscles as they clench.
❑ CN 7 (Facial)-Look at facial asymmetry. Ask patient to wrinkle forehead, shut
eyes tightly, grin, frown, shows teeth, and puff out cheeks.
❑ Note any lesions, deformities, dressings, size and shape
❑ Hair; evenly distributed, color, texture, balding patterns
❑ Mini mental exam: LOC and orientation to person, place, time, purpose
❑ Evaluate mobility/ROM of neck
o CN 11 (Accessory)-From behind; examine for shoulder asymmetry,
shrug shoulders, turns head against resistance
❑ Inspect Neck
o “Neck supple. Trachea midline. No neck masses.”
❑ Verbally address any issues related to this body system
❑ Complete
❑ Not Complete
Eyes: ❑ Follow Up
❑ Inspect eyes for alignment and symmetry
o “Eyes are symmetrical with good alignment.”
❑ Describe external eye structures
o “No abnormalities of the eye lids. Conjunctiva is pink. Sclera is white.
No excessive tearing or discharge.”
❑ Test extra ocular movements
o CN 6: Perform H pattern 15-18 inches from the patient nose. Finish
with convergence (AKA: 6 cardinal fields of gaze)
o CN 3, 4, and 6 (Oculomotor, Trochlear, Abducens) - PERRLA, direct
and consensual responses, ROMs using “H” pattern, convergence,
accommodation.
❑ “Extraocular movements for cranial nerves 3, 4, and 6
intact.”
❑ Check for papillary response to light, and accommodation.
o “Pupils 4mm constricting to 2mm, round regular, equally reactive to
light. Pupils accommodate to near and far vision.”
❑ Verbally address any issues related to this body system
