Brief&Adult&Physical&Assessment&

The$following$patient$data$are$to$be$observed$and$noted$during$a$15$minute$focused$physical$
assessment.$$Points$are$to$be$given$only$for$correct$assessments.$$$

Hint:$Be$sure$to$focus$most$carefully$on$the$system$at$risk$

Students&name_____________________________&&&Start&time&&______& &&&&&&&&&&&&End&time_____&

Observer___________________________________&

Points& Assessment&Item& Comment&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&

Points&&
Earned&
5$ Introduce$self$and$instructor$to$patient$ $$$$$$$$$$$$$$$$$$$$$$$$$$$ $
Explain$purpose$of$exam$
Maintain$privacy$$
Ensure$there$is$adequate$lighting$for$
exam$
5$ Wash$hands$before$exam$begins$AND$ $ $
after$leaving$room$
$
10$ Vital$signs:$$ $ $
Use$appropriate$cuff$size$as$needed$
Assess$for$pain$using$appropriate$pain$
scale$
Obtain$SPO2$
5$ Lines$and$Tubes:$$Verbalize$presence$of$ $ $
lines$and$tubes$$
IV:$date/time$label$on$line,$bag$and$
dressing.$$Checks$IV$site$
Foley,$NG,$surgical$drains:$notes$color$
and$consistency,$odor,$amount$
Oxygen:$source,$amount$
Other:$$
$
5$ Safety:$$ $ $
Call$light$within$reach$
Bed$in$low$position$
Siderails$$up$($4$siderails$up$is$
considered$a$restraint$and$must$be$
addressed$separately)$
Notes$special$precautions:$Fall$risk,$
aspiration$risk,$BP$
$
5$ Neuro$Assessment:$$ $ $
$LOC$(mini$mental$if$appropriate)$$
presence$of$any$abnormalities$
 Inspection$of$cranial$nerves$as$
appropriate$($ie:$eyes,$tongue,$facial,$
speech,$muscles,$hearing)$$
Tremors?$$
$
5$ Pulmonary$Assessment:$ $ $
Inspection$of$thorax,$auscultation$of$
breath$sounds$($anterior$and$posterior)$
Notes$respiratory$effort,$use$of$
accessory$muscles,$posture$if$SOB$
$
5$$ Cardiovascular$Assessment:$ $ $
Auscultation$of$heart$sounds$
Capillary$refill$
Peripheral$pulses$
Edema$
Skin$color$and$temperature$
$
5$ Gastrointestinal$Assessment:$ $ $
Inspection$of$abdomen,$$
Auscultation$$4$quadrants$
Light$palpation$as$appropriate$to$
diagnosis$
Note$special$tubes:$ie:$$colostomy,$NG,$
jejunostomy,$gastrostomy$
$
5$ Genitourinary$Assessment:$ $ $
Assessment$of$elimination$patterns.$If$
foley$in$place,$check$color,$consistency$
and$amount$of$urine.$$
Note$special$tubes:$ie:$CBI,$
Nephrostomy,$ureterostomy$
$
5$ Musculoskeletal$Assessment:$ $ $
Assess$for$hand/feet$strength,$
symmetry,$ROM.$$
Note$any$special$equipment:$skeletal$
traction,$CPM,$hip/knee/shoulder$
dressings/immobilizers$
$
5$ Integumentary$Assessment:$ $ $
Inspection$and$palpation$of$skin$noting$
color,$temperature$and$any$
abnormalities$
Check$bony$prominences$for$skin$
breakdown.$Observe$for$capillary$refill$
$
5$ Exam$completed$within$15$minutes$ $ $
$
5$ Communication:$Able$to$engage$with$ $ $
patient$in$a$calm$manner.$Explains$
procedure$to$patient$as$he/she$is$
performing$it.$$Allows$the$patient$to$
ask$questions.$Reassures$patient$as$
needed.$$
5$ Able$to$articulate$to$instructor$ $ $
diagnosis$and$assessment$findings$
$ Total&Points&Received&(out&of&100& $ $
possible&points)&&
$