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ATI’S SKILLS MODULES 2.0 CHECKLIST FOR PHYSICAL ASSESSMENT (ADULT)
GENERAL
INITIAL
COMMENTS
Verify prescription
Patient record
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Assess for procedure need.
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Identify, gather, and prepare equipment and supplies
Level of consciousness, general patient survey, vital signs
(height and weight scale, body mass index calculator, pulse oximeter, thermometer, stethoscope, blood pressure equipment)
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Integument
(wound measuring device, tape measure)
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Head, face, neck (penlight, cotton ball)
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Eyes
(penlight, ophthalmoscope)
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Ears, nose, throat
(otoscope, penlight, tongue blade, fragrance)
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Respiratory
(stethoscope, pulse oximeter)
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Cardiac
(stethoscope, penlight)
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Abdominal (stethoscope)
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Musculoskeletal
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Neurological
(fragrance, penlight, reflex hammer, tongue blade, cotton ball, low-frequency tuning fork, monofilament)
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GENERAL
Apply principles of aseptic practice
Hand hygiene
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Personal protective equipment
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Disposal of waste
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Communicate effectively
Privacy
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Patient identification
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Patient teaching
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Provide for a safe environment
Body mechanics
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Equipment placement
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Patient safety
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Demonstrate procedural steps
Level of consciousness, general patient survey, vital signs
Assess level of consciousness.
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Assess orientation.
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Observe skin color, respiratory effort, comfort level, pain.
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Observe posture and position.
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Observe mood and affect.
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Note facial expression.
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Note hygiene, grooming, and dress.
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Note odors.
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Note general body structure, height, weight, and BMI.
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Note mobility aids, medical equipment, dressings, and ostomies.
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Assess temperature, pulse, respiration, oxygen saturation, and blood pressure.
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Integument
Inspect head and scalp for color, hair distribution, and lesions.
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Inspect for infestations.
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Inspect and palpate skin for texture, moisture, and temperature.
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Pinch skin fold over clavicle to check skin turgor.
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Note distribution of body hair on legs.
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Assess any wounds or lesions.
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Inspect for edema.
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Inspect nails of feet and hands.
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Check for clubbing.
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Check capillary refill.
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Inspect skin on posterior surfaces.
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Check for blanching on any reddened areas.
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Demonstrate procedural steps
Head, face, neck
Inspect head for size and shape, placement of features, and hair distribution.
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Examine face for symmetry.
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Observe skin of face.
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Palpate skull and hair.
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Test cranial nerve V by asking patient to bite down then close his eyes and report light touch.
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Test cranial nerve VII by asking patient to change facial expressions.
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Examine neck.
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Palpate carotid arteries.
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Check for thyroid enlargement.
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Check range of neck motion.
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Observe for jugulovenous distention.
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Locate and palpate lymph nodes.
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Check cranial nerve XI by having patient turn head to each side against resistance and shrug shoulders against resistance.
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Eyes
Note distribution of eyebrows and eyelashes.
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Look for drooping of upper lids or sagging of lower lids.
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Note color of sclerae and defects or inflammation of bulbar conjunctivae.
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Retract lower lids to note palpebral conjunctivae.
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Inspect each iris.
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Note size and shape of pupils.
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Shine light onto each pupil and note response.
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Observe pupils for accommodation.
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Check alignment.
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Check extraocular movement (six cardinal fields of gaze).
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Identify red reflex.
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Ears, nose, throat
Inspect ears for shape, placement, and discharge.
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Check for tenderness by palpating pinna and tragus of each ear and by percussing over mastoid process.
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Test hearing.
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Use otoscope to inspect ear canals and tympanic membrane.
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Check nose for alignment.
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Check that septum is midline.
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Note any discharge.
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Use penlight to check nasal mucosa.
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Check patency of nares.
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Check cranial nerve I by asking to identify scent.
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Assess mouth, lips, oral mucosa, gums, and teeth.
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Check tongue, throat, and tonsils.
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Test for rising uvula.
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Test ability to swallow.
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Check for midline tongue protrusion.
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Check articulation.
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Demonstrate procedural steps
Respiratory
Count respiratory rate while observing breathing pattern.
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Compare inspiratory and expiratory phases of respirations.
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Note posture.
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Ask about trauma, surgery, and other conditions that affect respiration.
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Note use of oxygen.
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Inspect thorax for symmetry and configuration.
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Note use of accessory muscles.
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Check posterior thorax for deformities.
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Palpate and percuss over anterior and posterior chest.
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Use diaphragm of stethoscope to auscultate over all lung fields.
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Check lung expansion.
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Cardiac
Review vital signs.
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Note overall condition (pain, respiratory status, level of consciousness).
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Inspect and palpate skin (color, moisture, temperature).
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Check color of palpebral conjunctivae.
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Palpate carotid arteries for rhythm and rate.
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Using bell of stethoscope, listen to carotid arteries for bruits.
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Test for jugulovenous distention.
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Check for apical pulsation.
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Palpate point of maximal impulse.
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Auscultate over five cardiac landmarks.
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Demonstrate procedural steps
Abdomen
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Observe contour from two angles.
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Note symmetry, contour, color, veins, lesions, scars, hair distribution, umbilicus, and abdominal movement.
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Auscultate bowel sounds in four quadrants.
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Using bell of stethoscope, auscultate abdominal aorta for bruits.
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Check for inguinal and umbilical hernias.
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Palpate four abdominal quadrants.
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Percuss four abdominal quadrants.
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Check for costovertebral-angle tenderness.
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Musculoskeletal
Inspect overall appearance and movement.
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Observe gait and balance (tandem, tiptoe, heels).
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Observe spine from lateral and posterior views.
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Check spine from lateral view, looking for normal curvatures.
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Palpate along spine.
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Inspect and palpate skin, joints, and muscle groups of upper and lower extremities.
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Test muscle strength of all limbs.
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Test range of motion of all limbs.
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Check pulses (radial, pedal).
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Inspect hair distribution on legs.
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Identify presence of edema.
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Assess gait and balance.
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Demonstrate procedural steps
Neurological
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Evaluate level of consciousness.
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Assess orientation.
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Assess mental status including mood and affect.
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Test immediate, recent, and remote memory.
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Test motor function and balance together with gait assessment.
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Perform Romberg testing.
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Test upper-extremity coordination.
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Test lower-extremity coordination.
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Assess 12 cranial nerves.
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Test muscle strength in upper and lower extremities.
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Test sensory function: light touch, sharp/dull discrimination, vibration, and monofilament testing on feet.
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Test deep tendon reflexes.
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Documentation
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Document per facility policy
LEVEL OF CONSCIOUSNESS, GENERAL SURVEY, VITAL SIGNS
Document patient’s level of consciousness and whether patient is oriented to person, place, and time.
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Describe patient’s general appearance
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Describe patient’s affect, or mood, as well as verbal and nonverbal behavior.
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Document temperature, pulse and respiratory rates, blood pressure, and pain level.
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Document per facility policy
INTEGUMENT
Note any recent changes in appearance or condition of patient’s skin.
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Describe texture of patient’s skin.
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Note temperature (warm or cool) of skin and whether it is moist or dry.
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Describe skin turgor.
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Describe size, shape, and appearance of any moles, lesions, bumps, or wounds.
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Document appearance of IV sites.
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HEAD, FACE, AND NECK
Note any pain or tenderness when palpating head, face, and neck.
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Describe hair distribution and note any areas of hair loss.
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EYES
Note position of eyes and color and condition of conjunctivae.
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Document PERRLA and EOMs.
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Note size, shape, and equality of pupils.
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EARS, NOSE, AND THROAT
Note position and appearance of ears.
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Describe appearance of internal ear.
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Note shape, skin color, and alignment of nose.
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Describe any inflammation or deformity of nose.
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Note any lesions, swelling, bleeding, or drainage.
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Inspect mouth and note hydration status.
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Note any discoloration of gums or any lesions.
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Document per facility policy (continued)
RESPIRATORY
Document respiratory rate, rhythm, and effort, or work of breathing, oxygen saturation, and oxygen use at time of exam.
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Note symmetry, configuration, and any deformities of thorax.
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Note any pain or tenderness over thorax.
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Document percussion findings and chest expansion.
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Describe breath sounds and abnormal sounds.
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Document amount, color, consistency, and odor of sputum.
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CARDIAC
Document cardiac rate and rhythm.
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Document size and location of PMI, if visible, and presence of any lifts, heaves, or thrills with palpation over apex and other precordial landmarks.
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Describe heart sounds and any extra sounds, such as murmurs, split heart sounds, or friction rubs.
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Document presence or absence of jugular venous distention.
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Note capillary refill.
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Document any peripheral edema.
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Describe peripheral pulses.
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ABDOMEN
Note color of skin over abdomen, and any scars, rashes, lesions, or striae.
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Describe abdominal contour and symmetry and status of umbilicus.
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Document bowel sounds in all quadrants.
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Document presence of any bruits.
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If you percussed abdomen, document tone generated.
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Document palpation findings: whether abdomen is soft, firm, or distended, and any tenderness, rebound or otherwise, and any masses.
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Document per facility policy (continued)
MUSCULOSKELETAL
Note ambulation status and any mobility aids.
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Describe gait and posture.
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Document configuration and range of motion of spine.
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Document muscle mass and joint symmetry in upper and lower extremities.
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Document muscle strength and joint range of motion.
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Note amplitude and symmetry of peripheral pulses.
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Note results of Romberg testing.
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NEUROLOGICAL
Note level of consciousness and orientation to person, place, and time.
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Describe affect, or mood, and memory, if tested.
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Document whether or not cranial nerves are intact.
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Document gait, balance, and coordination in upper and lower extremities.
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Document findings of sensory testing: light touch, sharp/dull discrimination, vibration, and monofilament testing.
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Document deep tendon reflexes and Babinski reflex, if done.
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Comments
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SCIENCE
HEALTH SCIENCE
NURSING
