Jesus meets Martial Arts meets Nursing School

LONG POST – what I did for homework

Here is what I typed up to study by. It is the BASICS of doing an assessment. These are required when a patient first arrives at the facility. This is known as an Initial Assessment. Should be completed in 15 minutes or less! OMG! Happy reading, and I understand if you choose to skip this post! lol — sandanrn



Equipment: BP cuff, stethoscope, thermometer, pen light, tongue depressor, tape measure, reflex hammer, clean gloves, scale, alcohol swab, cotton ball, wrist watch, draping



  1. Inspect
  2. Palpate
  3. Percussion
  4. Auscultation


Except abdomen which is look, listen, feel.

v  Introduction

  • Knock
  • Enter Room
  • Introduce self
  • Explain procedure.
  • Wash hands (ask how they are doing and if feeling any pain. Address this first.)
  • Ask if they need to void before beginning assessment.


v  Health History

  • Medications
  •  Allergies to medication or food
  •  Past surgeries
  • Medical Problems
  • Family History
  • Alcohol, Cig, Drug Use
  • Recent Falls (Fall Risk)
  • Belongings (DOCUMENT the path every belonging takes ie. To safe, home with relative, etc.)


v  General Survey

  • Vital Signs
  • temp (thermometer)
  • pulse (wrist watch)
  • respirations
  • bp (sphygmomanometer)
  • pain (follow-up)
    •  Height and Weight (tape measure, scale)
    •  Racial or ethnic variations


v  Psychosocial Status (affects physical recovery)

  • How do you feel?
  • Any recent changes?


v  Neurological System

  • Level of consciousness – are you alert?
  • Orientation (oriented x3)
    • name?
    • year, who is president?
    • where are you?
    • Language
      • voice clear?
    • Memory

¨       STM (paper, pencil, pen… explain for them to remember the words because you will ask them to repeat later)

¨       LTM (birthdate)

  • Affect

¨       looking for congruency between mood and affect

  • Motor Function

¨       -flacid (can be moved, but you have to move it for them)

¨       contracture (rigid, fixed in place)

  • Sensation  (cotton ball, alcohol swab)

¨       upper and lower extremities on both sides for dull (cotton ball) and sharp (corner of alcohol swab packaging) sensation



Strength (use only 2 fingers for safety!)

¨       -squeeze with each hand

¨       press against hands with hands and feet (gas pedal)






 (HEENT – head eyes ears nose throat/mouth)

  • Head

¨       scalp (dandruff)

¨       hair (thinning)

  • Eyes (PERRLA: pupils equal, round, reactive to light, accommodation) (pen light)

¨       accommodation- focus on near then far object, pupils should dilate

  • Ears

¨       Whisper Test (stand behind client and whisper word behind each ear)

¨       Insp- Look at

¨       Palp- temperature, pain, tenderness

  • Nose

¨       Insp- symmetry to face and side to side, drainage, incrustations (boogers), deviated septum, see if nares are patent/open.

¨       -Palp- occlude each nare and check for patency, sinuses for tenderness


  • trouble swallowing? Thin/thick liquids?
  • -Insp- midline, drooping, color, sores, dryness, cryptic tonsils, uvula, tonsils, frenulum of tongue midline
  • -JVD- Jugular Vein Distinction – is it showing? (JVD is negative if you don’t see it.)

        Coratid- graded 1+, 2+, 3+ (quality of pulse, both sides), check for bruit (squishing sound)


         Oral Mucosa (tongue depressor)

  • -flacid (can be moved, but you have to move it for them)
  • contracture (rigid, fixed in place)



Integumentary System

DANGER SIGNS FOR CANCER ARE A.B.C.D.- Asymmetry, Border irregular, Color varied, Diameter >eraser

  • 1.Intact (clean and free from odor)
  • 2. Skin Color (pale/pallor, blue/cyanosis, red/erythemia, yellow/jaundice)
  • 3. Edema (pitting or nonpitting)
  • Turgor (check inferior to clavicle on older pt.)

¨       pull gently on back of wrist and see if skin returns or is “tenting”

  • Lesions: alteration from normal

¨       If found:

  • -document location and size

¨       look for drainage

Nail Assessment (free of polish and acrylics)

  • insp- lines, beau’s line, capillary refill ❤ sec.
  • Rashes
  • Temperature (esp. at joints)


v  Cardiovascular System (stethoscope)

  • Insp- short of breath?
  • Palp- for tenderness
  • Ausc-
    •  is it regular pulse or irregular? Any addt’l sounds?
    • A Point To Memorize!

¨       Aortic (S1 louder) – right sternal border, 2nd intercostal space

¨       Pulmonic (S1)- left sternal border, 2nd intercostal space

¨       Tricuspid(S2)- left sternal border, 4-5th intercostal space

¨       Mitral (S2)- mid clavicular line, 5th intercostal space

  • Count apical pulse for one full minutE



v  Respiratory System (stethoscope)

Insp- short of breath?

  • Check for diaphragmatic excursion (put thumbs together on spine, they should sep. approx. 5cm during inhalation and go back together at exhalation)
  • Check for tactile fremitus (put hands behing lungs and have them say “99” to see if vibrations are congruent)
  • Palp- for tenderness
  • Ausc-
    • What sounds are present?

¨       NORMAL

  • Bronchiole (neck area)
  • Bronchovascicular (near clavicle)
  • Vasicular (everywhere else)

¨       ADVENTITIOUS (Abnormal)

  • Crackles
    • Coarse (thick paper rubbing together)
    • Fine (record player popping, higher pitch)
    • Wheezing (tightening of airways)
    • Rochi (gurgles) – sounds like ppl talking in adjacent room (fluid)
    • Stridor (partial block of airway)

¨       ABSENT

  • Worsened closing of airway
  • FATAL if left untreated



v  Breast Exam

Insp- lumps and tenderness

                – raise arms and lower (looking for changes in swelling or nipples)

                -palms together and push (looking for retraction)

                – extend arm up and hand behind head, pillow under shoulder so breast is flat

                                – move in circular, star, or up and down pattern palpating for masses/pain



v  GI System (stethoscope) LOOK,LISTEN,FEEL!

  • Ask : passing stools regularly? When was last stool? Any pain?
  • Insp- symmetry, skin integrity, distension (bloated)
  • Check abdominal girth at umbilicus (tape measure)
  • Ausc- bowel sound in all four quadrants

¨       <5 hypoactive

¨       5-30 normal

¨       >30 hyperactive

  • Palp- for tenderness, lumps, or lesions


v  Genitourinary System

  • Urinary Output
    • Color, amount (30cc/hr), frequency
    • Continence
    • Catheter (is it draining urine)
    • Ask : passing stools regularly? When was last stool? Any pain?
    • Insp- symmetry, skin integrity
    • Palp- tenderness, distension (bloated)


                Insp- symmetry, rashes, odor, drainage

                Palp- tenderness, lumps, lesions


v  Musculoskeletal System

  • ROM
    • Full or limited?
    • Passive(you do it), Active (they do it)
    • Strength, Sensation
    • Termperature (warmth of joints)
    • Insp- edema, symmetry, tremors, deformities, color, bruises, rashes
    • Circulation/ Neurovascular Checks –IMPORTANT
    • Lesions, lumps
    • Pain,crepitus
    • Reflexes
    • Homan’s Sign (pull foot toward head, major pain in back of calf)

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