UNIVERSITY OF LA SALETTE COLLEGE OF NURSING CLINICAL EVALUATION TOOL PHYSICAL ASSESSMENT PERFORMANCE CHECKLIST NAME OF STUDENT: __________________________ DATE:

____________ YEAR/SECTION: ______________________________ SCORE: ___________ RATING SCALE 1 : not done or incorrectly done 3 : correct measures, but with inadequate description of findings; or not systematic In performance 5 : correctly done, systematic according to standard; with correct findings NA : not applicable PARAMETERS 1 A. GENERAL PHYSICAL SURVEY I. Observe appropriate guidelines for physical assessment a. Greets client appropriately b. Identifies self c. Explains the procedure d. Provides privacy e. Assists client in comfortable position II. Assess the following a. physical development, behavior, mood/affect, dress, grooming/hygiene, gait, body build b. vital signs BP ______ PR ______ RR ______ Temp ______ c. height: _____________ weight: _____________ d. pain yes _____ no ______ if yes, identifies COLDSPA of pain e. mental status B. INTEGUMENT I. Skin a. Inspects for general color variations, skin breakdown, lesions b. Palpates for presence of lesions, for texture, temperature, mobility, turgor, edema II. Scalp and Hair a. Inspects, color, amount and distribution b. Inspects and palpates for thickness, texture, oiliness, lesion, parasites III. Nails a. Inspects for grooming and cleanliness, color, markings and shape b. Palpates for texture and consistency c. Tests for capillary refill C. HEAD AND NECK I. Head and Face a. Inspects head for size, shape, masses, lesions b. Palpates head for consistency, presence of lesions SCORE0 3 5 N A REMARK S

c. Inspects face for symmetry, features, movement, expression, skin condition II. Neck a. Inspects neck for position, symmetry, presence of lumps/masses b. Inspects and palpates the thyroid gland, auscultates for bruits sound (if gland is enlarged) c. Palpates lymph nodes for size, shape, mobility, consistency and tenderness D. EYES a. Performs vision test b. Performs extraocular muscle function test c. Inspects eyelids, eyelashes, positioning of eyeballs, conjunctiva, sclera, cornea, iris, pupil d. Tests pupillary reaction to light e. Tests accommodation of pupils E. EARS a. Inspects for size, shape, position, lesions, discoloration, discharge b. Palpate auricles for tenderness c. Performs the Weber test d. Performs the RInne test e. Performs the Romberg test F. MOUTH, NOSE, THROAT, SINUS I. Mouth a. Notes any distinctive odors b. Inspect for color variations, moisture, tissue consistency, lesions c. Inspect, gums, teeth II. Throat a. Inspects for color, consistency b. Inspect tonsils for color, consistency, grading scale III. Nose a. Inspect for color, shape, consistency, patency, swelling, bleeding, lesions IV. Sinuses a. Palpate for tenderness G. THORAX AND LUNGS/CHEST I. Posterior and Anterior Thorax a. Inspect for shape, use of accessory muscle, posture while breathing b. Palpate for tenderness, lesions/masses, fremitus, chest expansion c. Auscultate for breath sounds, adventitious breath sounds II. Breast a. Inspect size, symmetry, color b. Palpate for texture, elasticity, tenderness, lesions, masses III. Heart a. Auscultate heart sounds for rate, rhythm H. ABDOMEN a. Inspect for color, vascularity, lesions, contour b. Auscultate for bowel sounds c. Percuss for tone d. Perform light then deep palpation e. Perform the following test:

i. Fluid wave test ii. Ballottement test iii. Tests for appendicitis iv. Test for cholecystitis I. EXTREMITIES a. Inspect for color, symmetry, lesions b. Palpate texture, temperature c. Palpate pulses J. GENITALIA I. Female Genitalia a. Inspect for lesion, infestation, swelling, excoriation and discharge b. Perform speculum examination II. Male Genitalia a. Inspect excoriation, infestation, rashes, lesions b. Inspect scrotum for swelling, lumps, bulges c. Inspect for inguinal and hiatal hernia K. ANUS, RECTUM, PROSTATE I. Anus and Perianal Area a. Inspect for lumps, ulcers, lesions, rashes, redness b. Inspect for rectal prolapsed with Valsalva maneuver II. Rectum and Prostate a. Palpate for tenderness, irregularities, nodules, hardness b. For males, palpate the prostate gland for tenderness, size, shape, texture, irregularities c. Inspect feces for blood L. OTHERS (if appropriate) I. Musculoskeletal a. Inspect for size, shape, symmetry, color, swelling, tenderness, nodules b. Test for ROM II. Neurologic a. Glasgow Coma Scale b. Cranial nerves c. Test condition and movement of muscles d. Test balance e. Test coordination f. Test reflexes

______________________________________ CLINICAL INSTRUCTORS NAME AND SIGNATURE