NURS 3614 Assessment Final Check-Off Example Script

[Knock before stepping into the exam room, making sure to close all curtains/doors after entering. Make sure lights are all on, and begin deliberately inspecting patient.] Hi, my name is ______, Im a student nurse at TWU and Ill be performing your assessment today. Can I have your name, please? Thank you, _________, Id like to ask you a few questions before we begin.

Subjective Data - History of Present Illness (HPI):

Id like to first get a bit of information from you, starting with your age. And your date of birth? What is your ethnicity? What is your occupation? [Demographic information dont forget to include name initials ONLY!] What brings you here today? WRITE DOWN FOLLOWING ____________________ (Subjective statement; document along with demographic information in SOAP.) O: L: D: C: A: R: T: S: P:

When did the pain/discomfort begin? (Onset) Where is the pain/discomfort located? Can you point to its exact location, please? How long does the pain/discomfort last? (Does it come and go (intermittent)?) (Duration) Can you describe the pain? (Burning, aching, stabbing, sharp, dull, any combination, etc.) (Characteristics) What makes it worse (aggravating)? Better (alleviating)? Any other (associated) pain/discomfort? Does the pain radiate or spread anywhere? (Referred) When is the pain the worst? Better? Continuous? Time of day? On a scale of 0 to 10, with 10 being the worst imaginable, please rate the severity of your pain/discomfort. (Document as X/10). How has this affected you? What do you think it means? (Patient Perception)

Inspection begins immediately upon greeting patient. [Make a verbal note of the patients appearance:]

Posture erect with no involuntary movements or signs of distress. Dress & grooming appropriate for season & setting. Hygiene good. Alert, oriented X3 (to person, place, time). Speech coherent, appropriate, clear Pleasant affect Moves all extremities well with good range of motion; Movement smooth & even. (Mobility & gait) Skin light beige color w/ light pink undertone. Evenly pigmented. (Few scattered macules, no cyanosis or circmoral pallor; noting any visible lesions, scarring, etc.) (Document with General Survey under Observation.)
Before we begin the objective date, Im going to wash my hands. While I step out to do so, please put on this gown, with the opening to the front and use this cover sheet to cover yourself for privacy and to keep warm (unless starting with thoracic, then open to the back). [Make sure to provide patient with a gown and cover sheet before leaving the room. Close all doors/curtains completely when leaving. Knock before stepping back in, and again, close all curtains/doors completely behind you. This is a good opportunity to gather/organize supplies needed and think about the order in which to proceed.]

NURS 3614 Assessment Final Check-Off Example Script

Vitals, Turgor, Capillary Refill: (Watch, Thermometer, Blood Pressure Cuff

Correct Size, Teaching Stethoscope, Alcohol Swabs) Now I am going to take your vital signs and then we will begin the exam and take a look at what brought you here today, okay? If at any point you feel become uncomfortable or feel any pain, please let me know. I would like to apologize ahead of time for any discomfort you may feel during the exam. [Make sure on right side of patient & gather appropriate tools before beginning.] Temperature: Lets begin with your temperature: have you had anything to eat or drink in the last 15 minutes?Have you smoked, exercised, or chewed gum in the last 2 minutes? [Place probe cover on thermometer] [temperature is ____ degrees F; taken orally/axillary.] Pulse (compare bilaterally): Then count 30 seconds. [Pulse is ___; regular; 2+; equal bilaterally] Respirations (right after count pulse shift gaze, count 30 or 60 seconds): [Respirations are ____ breaths per minute; even; unlabored] Capillary Refill: [Brisk capillary refill; <2 seconds; nail bed pink, without clubbing] Blood Pressure: Im going to first make sure the cuff fits appropriately by making sure the width of the bladder is 40% the circumference of your arm and the length of the bladder is 80% of the circumference of your arm. Im going to palpate your brachial artery to assure correct placement and then go 1 above the antecubital fossa. [Make sure legs are not crossed.] What is your normal baseline blood pressure? [Blood pressure is ___ over ___, seated, right arm...] Turgor: Checking turgor. Brisk skin return; no tenting. Pain: What is your pain level right now on the pain scale? Are you feeling any discomfort?

NURS 3614 Assessment Final Check-Off Example Script

Objective Data & Systems Assessment:

Ok, Ms. Carr, Id like to take a look at (CC/first system to assess).

Skin Assessment: [In affected area]

Color: skin is light beige color, pink pigmentation, few macules Turgor: brisk return, no tenting Temp: warm Moisture: dry Lesions: no lesions [MUST DESCRIBE & DOCUMENT AT LEAST ONE LESION IN AN AFFECTED AREA This is a critical!] Capillary Refill: Brisk capillary refill, nail bed pink, no clubbing Tattoos: ?? [If any]

Document Skin: (Under General Survey) Skin light beige with even pink pigmentation; warm, dry, intact, no lesions or scars (or describe lesion in affected area), no tattoos; turgor: brisk return, no tenting.

Head and Face (4): (No Equipment Needed)

Inspect & Palpate 1. Scalp, Hair, Cranium: Head is normocephalic, symmetric & smooth; no lumps, lesions, or tenderness. Hair is even in distribution & thick texture. Face symmetric, no involuntary movements, skin color is light beige with few macules, no nevi. Warm to touch, dry, smooth and even. Smiling facial expression, no edema, masses or lesions (describe a lesion, scar, etc.). Palpate 2. Temporal artery: Temporal artery regular, 2+, bilaterally. 3. Temporomandibular joint (CNV): (have person open & close mouth) Temporomandibular joint movement is smooth, with no limitation, tenderness or crepitation. 4. Palpate maxillary and frontal sinuses: No tenderness to palpation of frontal or maxillary sinuses.

Document Head & Face: Head normocephalic, symmetric, smooth; no lumps, lesions, or tenderness. Hair distribution even & thick texture. Face symmetric, no involuntary movements, skin color light tan with few macules. Warm to touch, dry, smooth and even. Relaxed facial expression, no edema, masses or lesions. Temporal artery is regular, 2+, bilaterally. TMJ movement is smooth, with no limitation, tenderness or crepitation. No frontal or maxillary sinus tenderness upon palpation.

NURS 3614 Assessment Final Check-Off Example Script

Eyes (8): (Card to Cover Eye, Pen Light, Opthalmoscope)

Inspect: 1. Lids, Position, Lashes, Brows: Normal upper lids overlap superior part of iris, skin intact, no swelling, discharge or lesions. Eyeballs aligned normally in their socket, no protrusion or sunken appearance. Eyeballs look moist and glossy. Brows and lashes are present bilaterally; symmetrical; no ptosis 2. Conjunctivae, Sclera, Cornea: Conjunctiva clear with normal color; sclera china white; Cornea and iris intact with no opacities 3. PERRLA: [RL: Gaze into distance, advance pen light from side; do on both eyes; direct & consensual response; A: Focus on distant object; then sift gaze to my finger, held 3 from nose.] Pupils bilaterally are equal, round, reactive to light (directly & consensually) & accommodation 4. Corneal light reflex: [Tell patient to stare straight ahead as hold light 12 inches away. Note reflection of light on corneas.] Corneal light reflex symmetric bilaterally 5. Visual Fields by confrontation (CN II): [Eye level w/patient 2 away/arms length. Tell her to cover one eye with card, and with the other eye look straight at me. Cover my eye with card. Tell will be flicking finger and slowly moving it from periphery to midline, when you see my finger say now. Do at 3 positions each side.] Peripheral fields intact bilaterally 6. Extraocular movements: (6 positions) (CN II, IV, VII) [6 positions, using finger have pt follow finger w/out moving head; Start at center, slowly moving outward, holding at extremes] ye movement tracks parallel and cranial nerves III, IV, VI intact; no nystagmus; no lid lag 7. Cover-uncover test (CN III, IV, VI) [Ask patient to stare straight ahead at my nose even though the gaze may be interrupted. With card, cover one of patients eyes. Note response of uncovered eye. Now uncover other eye and observe for movement. Do other eye.] No eye weakness and no deviation in alignment observed 8. Ophthalmoscope use and view of red reflex [Pt stares at distant object, use same hand as pts eye; Place free hand on pts shoulder. Do other eye.] Red reflex present bilaterally

Document Eyes: Brows, lashes present bilaterally, symmetrical, no ptosis. Normal upper lids overlap superior part of iris; skin intact with no swelling, discharge or lesions. Eyeballs aligned normally in socket, no protrusion or sunken appearance. Eyeballs look moist and glossy. Conjunctiva clear with normal color; sclera china white; Cornea and iris intact with no opacities. Pupils equal, round, reactive to light and accommodation (PERRLA). Corneal light reflex symmetric bilaterally. Peripheral fields intact bilaterally per confrontation. Intact extraocular movements (EOMs), Cranial nerves III, IV, VI, evidenced by parallel tracking of the finger with eyes, no nystagmus. Cover-uncover test yields no extra movement or nystagmus. Red reflex present bilaterally

NURS 3614 Assessment Final Check-Off Example Script

Ears (4): (Otoscope)

Inspect 1. External ear: Equal size bilaterally, no swelling or thickening. Skin color is consistent with facial color. No lumps, lesions, masses, or discharge. Palpate 2. Auricles & Tragus: Pinna & tragus firm and movement produces no pain 3. Otoscope: [1) Place pinky finger on pts neck for support; 2) Rest tip of otoscope in pts ear canal; 3) Look into otoscope; 4) Pull pinna up & back as needed.] Tympanic membrane is pearly gray; cone of light @ 5 oclock (right ear) or 7 oclock (left ear). Test 4. Whisper test: [Tell patient to place a finger on the tragus and rapidly push it in and out of the auditory meatus. Shield lips so they cannot see. Whisper combination of 3 random letters & numbers & have pt repeat; do other ear - 5, B, 6; A, 4, L] Whispered words heard bilaterally; Cranial nerve VIII intact bilaterally

Document Ears: Ear size equal bilaterally, no swelling or thickening; skin color consistent with facial color; Pinna & tragus firm and movement produces no pain; no lumps, lesions, masses or discharge. Ear canal clear with no redness, swelling, lesions, foreign bodies, or discharge. Tympanic membrane pearly gray color with cone of light present bilaterally; no perforations bilaterally; cranial nerve VIII intact bilaterally via whispered words test.

Nose (3): (Gloves, Otoscope, Pen Light)

1.

Palpate bridge and soft tissue Nose symmetric, midline, in proportion to other facial features, with no deformities, inflammation, or lesions. Inspect nasal septum and turbinates: [Lift tip of nose with finger and insert wide-tipped speculum on the otoscope into the nasal vestibule. Inspect with pts head erect first, then tilted back. Turbinates red, smooth, moist; no drainage, swelling, lesions, or polyps; no septum deviation, bleeding or perforation. Assess for nasal patency [Push her nasal wing shut with your finger while asking the person to sniff inward through the other naris.] Nares patent bilaterally OR Left nares occluded, etc.

2.

3.

Document Nose: Nose symmetrical, midline, in proportion to other facial features, with no deformities, inflammation, or lesions; w/out septum deviation, bleeding or perforation. Turbinates red in color w/ smooth moist surfaces; no drainage, swelling, lesions, or polyps. Nares patent bilaterally.

NURS 3614 Assessment Final Check-Off Example Script

Mouth and Throat (7): (Gloves, Tongue Depressor, Pen Light)

Inspect & Palpate 1. Lips for Color, Swelling, Ulcerations: Lips are pink and dry with no swelling or ulcerations; no circumoral pallor or signs of cyanosis 2. Buccal mucous membranes for color or lesions: (Use pen light to inspect inside mouth!!) Buccal mucosa & gingivae pink, no nodules or lesions 3. Teeth for caries or pain: [Assess for pain by using tongue depressor to tap teeth with force] All teeth present, no discoloration, in good repair, no sign of caries; no sign of pain; no halitosis 4. Tongue and undersurface of tongue (CN: IX, X, XII): [Ask pt to touch tongue to roof of mouth; stick tongue out] Tongue smooth, pink, protrudes midline, no tremor, loss of movement or deviation to side, Cranial Nerve XII intact; ventral surface smooth, glistening, show veins; saliva present 5. Inspect oral cavity w/pt saying ah and movement of uvula (CN: IX, X): Uvula & soft palate rise in the midline, Cranial Nerves IX & X intact 6. Grade tonsils: Tonsils pink, 2+; no exudate or petechiae present. 7. Observe swallowing (CN: IX, X): Swallowing intact; Cranial Nerves IX & X intact

Document Mouth & Throat: Lips free of ulcers, swelling, no signs of cyanosis or circumoral pallor. Mucosa and gingivae are pink, no nodules or lesions; All teeth present, no discoloration, in good repair, no sign of caries, no sign of pain; no halitosis. Tongue smooth, pink, and protrudes midline with no tremor, loss of movement or deviation to side, Cranial Nerve XII intact; ventral surface smooth, glistening, show veins; saliva present. Uvula and soft palate rise in the midline upon phonation, Cranial Nerves IX and X intact. Tonsils pink, 2+, no exudate or petechiae present. Swallowing observed, Cranial Nerves IX and X intact.

NURS 3614 Assessment Final Check-Off Example Script

Neck (16): (No Equipment Needed)

Inspect 1. Symmetry, lumps, pulsations: Head positioned midline; accessory muscles symmetrical. Head is held erect & still; neck is without lumps or pulsations (or carotid pulsation observable bilaterally/lt/rt). Palpate 2. Masses, Tenderness: No masses or tenderness present 3. Preauricular node 4. Posterior auricular node 5. Occipital node 6. Submental node 7. Submandibular node 8. Jugulodigastric/Tonsilar node 9. Superficial cervical node 10. Deep cervical node 11. Posterior cervical node 12. Supraclavicular Naming all nodes as palpating; no lymphadenopathy 13. Trachea: [Place index finger in sternal notch, slip it off to each side; space should be symmetric on each side] Trachea midline 14. Carotid pulse: [palpate only one side at a time] 2+, even bilaterally 15. ROM (CN XI) [With ROM ask patient to touch the chin to the chest, turn the head to the right and left, try to touch each ear to the shoulder and to extend the head backward. Test strength of neck muscles by resisting the patients movements as they shrug their shoulders and turn their head to each side. ] No limitation of movement, motion smooth & controlled with full range of motion; Cranial Nerve XI intact 16. Muscle strength of neck: [Resist pts movement as she shrugs her shoulders, turns head to each side] Strength 5/5, 100%

Document head & neck: Head positioned midline, held erect & still; accessory muscles symmetrical; neck is without lumps or pulsations (or carotid pulse observable bilaterally/left/right); No masses or tenderness; no lymphadenopathy; trachea midline; Carotid pulse 2+ and even bilaterally; Neck supple with full range of motion, no pain; neck strength 5/5, 100%.

NURS 3614 Assessment Final Check-Off Example Script

Thoracic (9 - 16 total): (Stethoscope) *Patient has gown open to back Begin with Posterior
Inspect: 1. Thoracic cage configuration: AP (anteriorposterior) diameter < transverse diameter; respirations even, unlabored 2. Symmetry: Thorax symmetric bilaterally, elliptical shape, scapulae placed symmetrically 3. Color, Temperature, Masses, Tenderness: Color even, texture smooth, skin warm & dry; no lumps, masses, or lesion; no tenderness Palpate: 4. Symmetric expansion [Place warmed hands on the pts back w/thumbs at level of T9 or T10. Slide hands medially to pinch up small fold of skin between thumbs. Ask pt to take deep breath. Thumbs should move apart symmetrically.] Chest expansion symmetric; No lag in expansion 5. Tactile Fremitus: [6 places posterior, 5 lateral, 4 anterior; touch the pts chest w/ulnar edge of hand while you ask her to repeat ninety-nine. Start over lung apex. Go across & down to compare bilaterally] Tactile fremitus equal bilaterally 6. Spinous Processess: Spinous processes aligned straight; imaginary line from head through spinous processes, equal horizontal positions for shoulders & scapulae; nontender to palpation; no nodules, masses, or lesions 7. CVA Tenderness: [Place hand over 12th rib at costovertebral angle on back; thump that hand with ulnar edge of other fist pt feels thud but no pain] No CVA tenderness Percuss 8. Lung Fields: [Same locations as tactile fremitus (6x + 3 pos/lat) Start at apices (top of shoulders) and percuss over normal resonant tissue; 6 places posterior, 3 lateral, 4 anterior; Flat over scapulae & Dull over lungs] Resonance predominates over lung field Auscultate (Listen in same locations as tactile fremitus & percussion) 9. Breath Sounds: [Sitting, leaning forward slightly, hands in lap; Ask patient to take deep breath at each location (through mouth), hold diaphragm firmly on the pts chest wall & listen for full respiration, including full exhale side to side comparison] Vesicular breath sounds clear over lung fields; No adventitious breath sounds

NURS 3614 Assessment Final Check-Off Example Script

Anterior Thoracic (7) *Have pt turn gown open to front, using cover sheet for privacy, keeping eye contact, ready to catch pt if falls
Inspect 1. Symmetry: [Place hands on chest with thumbs along the costal margins pointing toward the xiphoid process (under breast tissue). Ask to take deep breath.] Chest symmetrical bilaterally; No lag in expansion 2. Use of accessory muscles: No use of accessory muscles; facial expression relaxed 3. Color, Texture, Temperature, Turgor: Color even, texture smooth, skin warm & dry; Turgor: brisk return, no tenting Palpate (4x) 4. Tactile fremitus [Compare vibrations from one side to other as they say ninety-nine (p.459)] Tactile fremitus equal bilaterally 5. Masses, Tenderness: No lumps, tenderness or lesions (Can also combine & do turgor, skin temp, & moisture at this time). Percuss (4x) 6. Lung Fields: [Begin in supraclavicular area, then to interspaces (not over breast tissue)] Resonance predominates over lung field. Auscultate 7. Breath Sounds: [Same areas as percussed, listen to one full respiration at each location, compare side by side.] Vesicular breath sounds clear over lung fields; No adventitious breath sounds

Document Thorax: -Posterior and Lateral: AP < transverse diameter; Thoracic cage is symmetrical bilaterally; skin color even, warm, dry; no lumps, masses, or lesions; symmetrical expansion with no lag; tactile fremitus equal bilaterally; spinous processes midline; no CVA tenderness; resonance dominates over lung field; vesicular breath sounds clear over lung fields; no adventitious breath sounds. -Anterior: Anterior thoracic cage symmetrical; no use of accessory muscles, facial expression relaxed; color even, texture smooth, skim warm and dry, turgor shows brisk return, no tenting; tactile fremitus even bilaterally; resonance predominates over lung field; vesicular breaths clear, no adventitious breath sounds.

NURS 3614 Assessment Final Check-Off Example Script

CARDIOVASCULAR (8): (Stethoscope) (Patient supine) Inspect & Palpate 1. Precordium: [Use palmar aspect of your four fingers, and palpate the apex, left sterna border, and the base.] Color even, texture smooth, skin warm & dry; no visible or palpable pulsations, lifts, heaves, or thrills 2. Carotid Arteries: [palpate carotid artery on each side individually] Carotid pulse regular, 2+, equal bilaterally Auscultate: (I run through the APE To Man areas with one side (bell) while stating aloud the location in which I am listening; then repeat using other side (diaphragm) & again stating where I am listening) 3. Aortic area with Bell & Diaphragm: 2nd Right intercostal space 4. Pulmonic area with Bell & Diaphragm: 2nd Left intercostal space 5. Erbs Point with Bell & Diaphragm: 3rd Left intercostal space 6. Tricuspid area with Bell & Diaphragm: 5th Left intercostal space, lower sternal border 7. Mitral area with Bell & Diaphragm: 5th Left intercostal space, midclavicular line 8. Inspect, Palpate, & Auscultate Apical Pulse: [Turn pt on left side, ask pt to exhale & hold it; palpate with one finger pad for rate, 30 seconds & multiply by 2, & give rhythm] I am palpating for the apical impulse at the 4th intercostal space, at left midclavicular line (or medial to midclavicular line); size is 1X2 cm; Rate is X beats per minute, regular;

Document Cardiovascular:

Skin over precordium even color, warm, dry, free of masses, lesions; no lifts, heaves, or thrills. Carotid pulse 2+ and equal bilaterally. Auscultated S1>S2 at the Apex; S2>S1 at the Base. Apical pulse palpated in the 4th intercostal space, left midclavicular line, 1X2 cm, rate X beats/minute, regular rhythm.

10

NURS 3614 Assessment Final Check-Off Example Script

Abdomen (7): (Stethoscope, Pillow)[Help pt to supine position, place pillow under knees,
stand on right side of pt] Inspect 1. Place a Pillow Under the Knees 2. Contour, Symmetry, Color: Abdomen rounded, symmetric; Skin is warm, dry, and smooth w/ no striae, scars, or lesions (document a lesion, scar, etc.) 3. Umbilicus and Pulsations: Umbilicus clean, inverted, & midline, no discoloration, inflammation, or hernia; Slight aortic pulsation visible beneath epigastric area Auscultate [1ST (Palpation can increase peristalsis, giving false interpretation of bowel sounds)] 4. Bowel Sounds [Use DIAPHRAGM; Start in RLQ (Right Lower); listen to 2 areas in each quadrant, moving clockwise] Normoactive bowel sounds, of 5 to 30 times per minute, heard in all 4 quadrants (Borborygmus is stomach growling) 5. Vascular Sounds in 5 Locations: [Listen w/BELL with firmer pressure] No vascular sounds heard over the aorta, left & right renal arteries, or over left & right iliac arteries Percuss All four quadrants: [Begin in RLQ, moving clockwise, right side of pt; zig-zag pattern; 2 places in each quadrant] Tympany predominates in all four quadrants Palpate Light Palpation: [Palpate with first four fingers close together, depress the skin about 1 cm in all 4 quadrants; start in RLQ; lift fingers, do not drag, moving clockwise] Abdomen soft with no masses or tenderness

Document Abdomen: Abdomen in rounded and symmetric; skin is warm, dry to touch, smooth, with no striae, scars, or lesions. Umbilicus is clean, inverted, midline, no discoloration, inflammation, or hernia; slight aortic pulsation visible beneath epigastric area. Normoactive bowel sounds heard in all four quadrants; No vascular sounds heard over aortic area, left and right renal arteries or over left and right iliac arteries. Tympany predominates in all four quadrants. Abdomen soft with no masses or tenderness upon light palpation.

11

NURS 3614 Assessment Final Check-Off Example Script

Neurological (14): (Cotton Ball, Long Cotton Swab to break for pain (sharp/dull), Tuning Fork for Vibrations, Small Objects for Stereognosis Reflex Hammer)
1. CN V: Sensation of face, light touch [touch, do not swipe, cotton ball to 5 areas of face; tell pt, When you feel this touch you, say, Now.] Cranial nerve V sensation intact & equal
bilaterally 2. Sensation of Arms & Hands (Sharp/Dull): Spinothalmic tract [Break cotton tipped applicator to use as sharp/dull easier than breaking a tongue depressor; leave 2 seconds between touches; touch 3 places on hand & 2 on arm in random, unpredicatable order, & have pt tell you location & sharp or dull; start outward & move up toward body] Pain sensation intact bilaterally 3. Sensation of Legs & Feet (Sharp/Dull): Spinothalmic tract [Touch 3 places on feet & 2 on legs; start outward & move closer to pts body] Pain sensation intact bilaterally 4. Kinesthesia: Test for position sense in affected areas (fingers or toes) [Grasp one finger or toe by the sides, have pt tell you up or down, doing one finger at a time] Position sense intact all four extremities 5. Vibratory Sense: Test Posterior Column Tract; test in affected areas (hands or feet) [Hit tuning fork with hand, do not touch fork, place base against a bony surface of fingers or big toe, then remove; have pt tell you when vibration starts & stops] Vibratory sense intact all four extremities 6. Stereognosis: [Place a common object in the palm of the pts hand, eyes closed; have pt identify object; repeat in other hand] Stereognosis intact bilaterally 7. Grapthesia: [Draw a number or letter on the palm of the pts hand, eyes closed; have them identify the number or letter; repeat on other hand; must draw on pts palm to their orientation] Grapthesia intact bilaterally 8. Upper Cerebellar: Finger to Nose test (you place your finger in front of pt, have them use index finger to touch your finger then touch their own nose you move your finger to different spots & have them touch your finger then back to their nose) OR Rapid Alternating Movements tests (pat knees with both hands, lift up, turn hands over, pat knees with backs of hands, repeat, getting quicker OR have pt touch thumb to each finger on the same hand, starting with index finger, then reverse direction) Upper cerebellar intact; able to perform RAMs smoothly with coordination bilaterally 9. Lower Cerebellar: Heel to Shin Test [Pt is in supine position, place heel on opposite knee & run it down the shin from the knee to the ankle; Normally pt moves heel in a straight line down the shin] Lower cerebellar intact; able to perform heel to shin smoothly with coordination bilaterally 10. Biceps Reflex: Deep Tendon Reflex (DTR) [Support pts forearm on yours; place thumb on biceps tendon & strike a blow on your thumb; Normal is contraction of biceps muscle & flexion of forearm] 2+ & equal bilaterally 11. Triceps Reflex: DTR [Suspend pts upper arm, letting in relax & dangle; strike triceps tendon directly just above the elbow; normal is extension of forearm] 2+ & equal bilaterally 12. Patella/Quadriceps Reflex: DTR [Let pts lower leg dangle freely; strike tendon directly just below patella; Normal is extension of lower leg] 2+ & equal bilaterally 13: Plantar Reflex: Superficial (Cutaneous) Reflex [Pts thigh in slight external rotation; Draw an upside-down J on the sole of the foot, up & inward across the ball of the foot; Babinski sign negative is normal, with Plantar Flexion; Abnormal is positive Babinski sign, with Dorsiflexion] No Babinski sign

12

NURS 3614 Assessment Final Check-Off Example Script 14. Romberg Test: Test Cerebellar Function [Have pt stand, feet together, arms at the sides; close eyes & hold position for 20 seconds; Normal is no swaying, falling, widening of base of feet, etc.; Stand close to person, ready for a fall stand to left or right side of pt with one arm in front of pt, one behind, ready to catch if falls] Negative Romberg sign

Document Neurological: Cranial Nerve V sensation intact and equal bilaterally; Pain sensation intact on hands, arms, feet, and legs bilaterally; Kinesthesia intact bilaterally, all four extremities; Vibratory sense intact bilaterally, all four extremities; Stereognosis intact bilaterally; Grapthesia intact bilaterally; Upper cerebellar intact via RAMs performed smoothly with coordination bilaterally; Lower cerebellar intact via heel to shin test performed smoothly with coordination bilaterally; Deep tendon reflexes: biceps, triceps, quadriceps all 2+ and equal bilaterally; No Babinski sign; Negative Romberg sign Neuro/Muskuloskeletal (5): (No equipment needed)
1. Observe Gait: [Tests Cerebellar Function Balance tests - Have pt walk across room away from you, stop] Gait smooth, rhythmic, effortless, & even 2. Observe Gait & Balance: [Tests Cerebellar Function Balance tests - Have pt turn around and walk back toward you; walk heel to toe gait (Tandem walk)] Tandem walk performed smoothly, maintaining balance 3. Observe Gait & Pain: [Tests Cerebellar Function Balance tests - Have pt walk on tiptoe away from you, then on heels back toward you] Able to perform walk on tiptoes; able to perform walk on heels 4. Observe ROM of Spine: [Tests Cerebellar Function Balance tests - Position yourself beside pt to catch a fall. Flexion/Extension (bend forward to toes, and backward); Rotation (Lateral bends left & right); Rotation (place hands on pts hips to keep hips straight, have pt turn upper body left/right)] Full range of motion of spine, with smooth motion & symmetry of movement 5. Have Patient Perform Shallow Knee Bend: Demonstrates normal position sense, muscle strength, & cerebellar function [Stand on one leg while bending the other leg at the knee; do with each leg be ready to catch pt if falls] Cerebellar function intact via shallow knee bends performed bilaterally; maintained balance bilaterally

Document Neuro/Muskuloskeletal: Gait smooth, rhythmic, effortless, even; Tandem walk performed smoothly, maintaining balance; Able to perform walks on tiptoes and on heels without pain; Full range of motion of spine, with smooth motion and symmetry of movement; Cerebellar function intact via shallow knee bends performed bilaterally, maintained balance.

13

NURS 3614 Assessment Final Check-Off Example Script

Upper Extremities (8) (No equipment needed)

1. Inspect for symmetry of shoulders, arms, hands, & fingers: Shoulders, arms, hands, & fingers symmetric bilaterally; Joints & muscles symmetric bilaterally; no swelling, masses, or deformities 2. Inspect nails beds, clubbing bilaterally: Nail beds pink bilaterally, capillary refill brisk bilaterally, no clubbing bilaterally 3. Inspect & palpate for color, temperature, texture bilaterally: Color even light beige with light pink pigmentation bilaterally ; skin warm and dry to touch with smooth texture bilaterally 4. Palpate epitrochlear nodes bilaterally: Epitrochlear nodes not palpable bilaterally; No lymphadenopathy of epitrochlear nodes ROM: Flexion/Extension; Abduction/Adduction; Rotation; Circumduction Remembr: 3 movements for each joint, except for 4 that have 4. 5. Shoulders (4): [Flexion & Extension; Abduct & Adduct; Internal & External Rotation (internal is behind back; external is behind neck); Circumduction of each shoulder] Shoulders: Full range of motion bilaterally; movement smooth with no crepitation or tenderness bilaterally 6. Elbows (3): [Flexion/Extension; Rotation (Pronation (palm down) & Supination (palm up)!!); NO abduct/adduct] Elbows: Full range of motion bilaterally; movement smooth with no crepitation or tenderness bilaterally 7. Wrist (4): [Flexion/Extension (bend back & forward); Abduct/Adduct (Ulnar & Radial deviation); Rotation (Pronation/Supination); Circumduction] Wrist: Full range of motion bilaterally; movement smooth with no tenderness bilaterally 8. Fingers (3): [Flexion/Extension (hand flat w/ fingers together, bring fingers up to hyperextend, then down 90); Flexion/Extension (part 2 make a fist/touch thumb to each finger & base of little finger); Abduct/Adduct (spread fingers (fan)/bring together)] Fingers: Full range of motion bilaterally; movement smooth with no tenderness bilaterally

Document Upper Extremities: Shoulders, arms, hands, & fingers symmetric bilaterally; joints & muscles symmetric bilaterally; no swelling, masses, or deformities. Nail beds pink bilaterally; capillary refill brisk bilaterally; no clubbing bilaterally. Skin color even, warm & dry to touch with smooth texture bilaterally. Epitrochlear nodes not palpable bilaterally. Shoulders, elbows, wrists, and fingers: full range of motion bilaterally; movement smooth with no tenderness or crepitation bilaterally.

14

NURS 3614 Assessment Final Check-Off Example Script

Lower Extremities (11): (No equipment needed)

(Knee/Hip ROM partially performed standing, other supine/sitting; take in to consideration other systems you are assessing to keep patient repositioning to a minimum)
Inspect: 1. Bilaterally for symmetry: Hips, knees, ankles, & toes symmetrical bilaterally; joints & muscles symmetric bilaterally with no swelling, inflammation, or deformities 2. Bilaterally for hair distribution: No leg hair present, consistent with patient verbalization of shaving Palpate Bilaterally: 3. Palpate bilaterally for temperature, turgor, moisture, & edema: Skin warm & dry to touch bilaterally; elastic turgor bilaterally; no edema bilaterally 4. Popliteal pulse: [Leg extended, but relaxed, anchor thumbs on knee & curl fingers around into popliteal fossa; press fingers forward hard to compress artery against the bone; often is just lateral to medial tendon; may turn pt prone & lift up lower leg; let leg relax in arm, press in deeply w/2 thumbs] A) Popliteal pulse not palpable bilaterally; OR B) Popliteal pulse palpable bilaterally/left or right, 1+ or 2+, regular bilaterally 5. Posterior tibial pulse: [Medial aspect, behind ankle] Posterior tibial pulses 1+/2+, regular bilaterally 6. Dorsalis pedis pulse: [Very light touch or will occlude; lateral to & parallel with extensor tendon of big toe] Dosalis pedis pulse 1+/2+, regular bilaterally 7. Check capillary refill bilaterally: Capillary refill of toes brisk bilaterally Perform ROM of: LYING FIRST 8. Hips: [LYING: Extension/Flexion w/leg straight (lift straight up, back down); Extension/Flexion w/knee bent (bring knee up to chest); Abduction/Adduction (leg straight, move away from body, then across midline); Internal & External Rotation (bend knee, keep hips on bed, rotate inward, then outward); STANDING: Flexion/Extension (leg straight, hyperextend forward, then flex back; be ready at pts side to catch a fall)] Hips: Full range of motion bilaterally; movement smooth with no tenderness or crepitation bilaterally 9. Knees: [STANDING: Extension/Flexion (be ready to catch if pt falls)] Knees: Full range of motion bilaterally; movement smooth with no tenderness or crepitation bilaterally 10. Ankles: [Extension/Flexion (Plantar Flexion point toes; Dorsiflexion toes toward self); Inversion/Everson; Circumduction] Ankles: Full range of motion bilaterally; movement smooth with no tenderness or crepitation bilaterally 11. Toes: [Flexion/Extension (curl toes/point toes up); Abduction/Adduction (spread/fan toes)] Toes: Full range of motion bilaterally; movement smooth with no tenderness or crepitation bilaterally [STANDING: Hip flexion/extension; Knee extension/flexion]

Document Lower Extremities:

15

NURS 3614 Assessment Final Check-Off Example Script

Hips, knees, ankles, and toes symmetric bilaterally; joints and muscles symmetric bilaterally with no deformities. No leg hair present, consistent with shaving. Skin warm and dry to touch bilaterally; elastic turgor bilaterally; no edema bilaterally. Popliteal pulse not palpable bilaterally (OR Popliteal pulses 1+/2+, regular bilaterally); Posterior tibial pulse 1+/2+, regular bilaterally; Dorsalis pedis pulse 1+/2+, regular bilaterally. Brisk capillary refill of toes bilaterally. Hips, knees, Ankles, and toes: All with full range of motion, bilaterally; smooth movement with no tenderness or crepitation bilaterally.

16

NURS 3614 Assessment Final Check-Off Example Script

At end of exam, after teaching:

(These are worth a total of 9 points. However, performing your teaching topic is a critical, so be sure to perform teaching first if low on time!)

1) Quickly and briefly review findings with patient. 2) Ask patient if she has any questions. 3) Thank the patient for her time.

DONT FORGET: Did you ask for pain rating on scale of 1-10? Did you check capillary refill? Did you check turgor? Did you describe the skin, including at least one lesion, scar, etc.? Did you take the patients temperature?
(People forget this a lot.)

17

NURS 3614 Assessment Final Check-Off Example Script

Now perform your teaching topic:

Testicular Self-Exam
Id like to talk to you about testicular self exam, with you can pass on to male loved ones in your life. This is a cancer-screening test that men can do themselves. The purpose for this is to look for an unusual lumps, swellings, tenderness, or excess fluid in or around the testicles. A helpful mnemonic is T-S-E, where: T is timing. All males should perform the self-exam once a month, starting in the teens. Testicular cancer peaks in men 20-39 years old. S is shower. Start the exam in the shower, when the hands are warm and soapy, and the scrotum is warm. Cold hands retract scrotal contents. The male may also stand in front of a mirror while performing the exam after the shower. It is normal for one testicle to be larger than the other. E is examine. Examine the testicles by supporting the testicles with one hand and feeling with the other hand. Roll each testicle between the thumb and fingers. The epididymis is on top and behind the testicle, and feels a bit softer. If you discover a hard mass in either testicle or a hard area, even as small as a grain of rice, tenderness, or an overall enlarged testicle, contact your health care provider quickly. Growths you may find may not be testicular cancer, but when testicular cancer is caught early it has a high cure rate.

Breast Self-Exam
Id like to talk to you about breast self-exams, which is an exam a person can perform on his or herself to help aid in breast cancer detection, which is the most common type of cancer in American women, and male breast cancer is on the rise. Perform the exam once a month, at the end of your period, when your breasts are not tender or swollen. For women who do not have a period, and for men, perform the exam the first day of every month or whenever you can best remember to do it monthly. These five steps make up the breast self-exam: 1. Begin the exam in the shower. The hands move more easily over soapy, wet skin. With your fingers flat, move gently over the entire area of the breast, starting at the nipple and working outward. Check for any lump, hard knot, or thickening. 2. Stand in front of a mirror. Look at the breasts with hands at your sides, then with hands raised above your head, then finally with hands pressed firmly on your hips. Look for lumps, new differences in size or shape, swelling, dimpling, or lag in movement with these maneuvers. It is common for the left and right breasts to differ in size. 3. Examine your breasts with your fingers while sitting or standing. Slowly and methodically press on the breast with the opposite hand. With your fingers flat, work in a circular or spiral direction, beginning at the nipple and working your way outward. 4. Lie down, repeating the previous step. Place a small pillow or rolled towel under the shoulder on one side and place that same arm under your head to help distribute the tissue more evenly. Using the opposite hand, examine the breast. 5. Squeeze the nipple of each breast gently between your thumb and index finger. Report any discharge or fluid to your healthcare provider right away. The most common site for breast cancer is the upper outer quadrant, so be sure to examine the axillary areas as well. Contact your healthcare provider as soon as possible if you notice a lump, swelling, skin irritation or dimpling, nipple pain or retraction, redness or scaly rash on nipple or breast skin, or a discharge. The majority of women will never get breast cancer, the majority of breast lumps are benign, and early detection of breast cancer yields a high survival rate.

18

NURS 3614 Assessment Final Check-Off Example Script

Osteoporosis Prevention
Id like to talk to you about osteoporosis, which thins and weakens the bones to the point where they break easily. Bones continue to grow, reaching their greatest strength at ages 20-35. After that, they slowly become weaker as you age, therefore the risk for osteoporosis increases as you get older, affects women more than men, and Caucasian and Asian women, especially slender women, have the highest risk. There may be no symptoms of osteoporosis until a bone breaks, often the hip, arm, or wrist. It may be diagnosed by an x-ray or bone mineral density tests. Risk is increased with a family history of osteoporosis, as well as modifiable behaviors. Treatment does not cure osteoporosis, but may slow down the bone loss and rebuild some bone. Treatment includes increasing calcium in the diet. Medications are available for those who do have osteoporosis, and those who have been diagnosed need to take precautions to prevent injury for the rest of their lives. Eating healthy foods, especially low-fat milk and diary products, green leafy vegetables, citrus fruits, sardines, and shellfish aids in keeping bones healthy. Take a daily calcium supplement. Women under 50 need 1,000mg per day, and women over 50 need 1,200mg per day. Vitamin D also helps the absorption of calcium in the bones, which can be obtained through milk, supplements, and sunlight. Regular weight-bearing exercise such as walking daily, limiting caffeine intake, and not having more than one alcoholic drink per day can aid in bone health.

Heart Disease Prevention

Id like to talk to you about preventing heart disease, which is the leading cause of death in Americans. Most heart disease is related to the way we live, and changing to a healthier lifestyle will help prevent both new and repeat problems. Heart attacks are more frequent in men than in women up to about age 50. Both men and women need to care for their health as they get older, as aging is an important risk factor for heart disease. Diabetes, high blood pressure, and high cholesterol are major risk factors for heart disease. Regular exercise helps: Blood circulation Keep blood pressure and cholesterol within normal limits Keep muscles in tone Prevent obesity Improves your mood Aerobic exercise is important for building and maintaining heart and lung efficiency. Adults should get at least 30 minutes of moderate aerobic exercise preferable daily. Try to walk at least a mile each day. Regular mild exercise is much better than occasional strenuous exercise. Smoking is a major risk for heart disease. It causes narrowing of the arteries, and you are more likely to form clots in the heart arteries. Smoking causes lung damage, which in turn can cause heart damage. Research has shown that smokers who quit reduce their risk for heart disease. Maintaining a healthy weight is important, as extra weight increases blood pressure, which puts extra strain on the heart, and increases risk for type 2 diabetes, which is a risk factor for heart disease. Eating a healthy, balanced diet reduces risk for heart disease. Diets high in cholesterol and saturated fat increase risk for artery disease, which is the main cause of heart attacks. Stress and how you handle it is a risk factor because is increases blood pressure and blood cholesterol. Relaxation techniques and avoiding stressful situations can help. Take time out, and hobbies can be helpful.

19

NURS 3614 Assessment Final Check-Off Example Script

SOAP Format Subjective: (Patient Demographics) Patient initials, XX year old, Date of birth: X/X/19XX, Caucasian female, nursing student. Reason for seeking care: __________. (Document patient statement in quotations.) Document OLDCARTS-P (Further history - anything to eat or drink recently, any hospitalizations, allergies, current medications.) Objective: General Survey: Alert and oriented X2 (person, time); posture erect; no involuntary movements or signs of distress. Conversive, speech, clear, appropriate. Ambulates with good coordination. Good range of motion in all extremities. Dress and grooming appropriate for season and setting. Vitals: Temperature: XF, oral/axillary; Pulse (compare bilaterally): X bpm, equal bilaterally, 2+, regular; Respirations: X rpm, even, unlabored; Blood Pressure: X/X, seated, left/right arm; Pain/Discomfort: X/10 Skin: The skin is light beige color, even pink pigmentation. Warm and dry to touch; intact with even surface, no lesions (describe a lesion, scar, etc.); elastic turgor, no tenting; Capillary refill brisk bilaterally System Assessment Data: <add objective system data here> Assessment: Knowledge deficit related to inadequate understanding of Bone Health / Cardiovascular Health / Testicular Cancer Self Screening / Breast Cancer Self Screening Plan: Teaching: Osteoporosis Prevention / Cardiovascular Disease Prevention / Breast Self Exam / Testicular Self Exam. (If time allows, may also add: Patient voiced understanding. Provided patient a pamphlet on X to take home. Follow up with questions or concerns.)

20