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Overview
- While it is impossible to list every possible disorder of the various body systems, this course will attempt to provide the outline for a basic physical assessment to allow the nurse the ability to determine if the patient has any outlying abnormalities. This is not intended to be a complete guide to pathophysiology but to provide a framework for completing a thorough head to toe assessment.
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- Checklist for General Assessment
Body Structure/Mobility
Behavior
Health HistoryVital Signs
Height Weight
Pulse Rate
Respirations
Temperature
Blood Pressure
PainIntegumentary
Inspect: color, moisture, hair, rashes, lesions, pallor, edema
Palpate: temperature, turgor, lesions, edema, textureScalp
Inspect: shape, symmetry
Palpate: tenderness, deformityNails
Inspect: shape, color
Palpate: capillary refillHead
Inspect: symmetry, shape, size, uniformityNeck
Inspect: symmetry, lesions, scars
Palpate: tenderness, lymph nodes, thyroid gland, TMJEyes
Inspect: interior and exterior, visual fields, acuity, reflexesEars
Inspect: color, shape, symmetry, interior inspection
Palpate: tenderness, deformityNose
Inspect: shape, symmetry, interior inspection
Palpate: frontal sinus, maxillary sinusesMouth and Throat
Inspect: exterior and interiorThorax and Lungs (anterior and posterior)
Inspection: respiration quality, symmetry, deformity, tracheal location
Palpation: tenderness, fremitus, chest expansion
Percussion: percussive tones, diaphragmatic excursion
Auscultation: breath sounds and qualityHeart and Great Vessels
Inspection: jugular venous pulse
Palpate: pulses, PMI
Auscultate: heart sounds (bell and diaphragm)Peripheral Vascular System
Inspect: color, edema
Palpate: temperature, edemaAbdomen
Inspect: discomfort, uniformity, color, symmetry, scars, hernia, peristalsis, pulsations
Auscultate: bowel sounds, bruits
Percussion: four quadrants, liver, spleen, renal tenderness
Palpation: light to deep, liver, spleen, aorta, rebound tenderness, fluid waveMusculoskeletal
Inspection: asymmetry, deformity, atrophy
Palpation: major joints, tenderness, deformity, range of motionNeurological
Inspect: mental status (health history), cranial nerves, coordination, movement, senses
Palpate: motor strength, muscle tone, reflexes, sensesGenitourinary
Inspect: general appearance, lesions, scars
Palpate: breast exam, testicular exam, prostate exam, vaginal exam, Pap smearLymphatic
Palpate: assess lymph node locations
- Checklist for General Assessment
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