FEU Nursing 08-09 - H.A. ETools

Far Eastern University

Institute of Nursing

2nd Semester 20008-09

Related Learning Experience

Health Assessment

Thorax, Abdomen Extremities

Cranial Nerves and reflexes

Evaluation Tool

Name:

Section: Group:

Clinical Instructor:

5	-	Consistently displays behavior even without supervision.
4	-	Always exhibit behavior with minimal supervision. Correct sequence was followed
3	-	Exhibits behavior most of the time when reminded. Sequence of proper order was not followed.
2	-	Exhibits behavior but needs constant supervision. Missed out some procedures, did not follow proper order
1	-	Rarely exhibits behavior even with reminder(s).
0	-	Does not exhibit behavior.
N.A.	-	Not Applicable due to certain circumstance(s)

PART II	5	4	3	2	1	0	N.A.	Remarks
Thorax
Posterior Thorax
1. Inspect the size, shape, symmetry, and compare the diameter of anteroposterior thorax to transverse diameter
2. Inspect the spinal alignment
3. Palpate for temperature, tenderness and masses
4. Assess respiratory excursion
5. Palpate vocal fremitus
6. Percuss the posterior thorax
7. Auscultate the posterior thorax
Anterior Thorax
8. Inspect breathing patterns
9. Palpate for temperature, tenderness and masses
10. Assess respiratory excursion
11. Palpate vocal fremitus
12. Percuss the anterior thorax
13. Auscultate the trachea
14. Auscultate the anterior thorax
Cardiovascular
Simultaneously INSPECT and PALPATE the precordium for the presence of abnormal pulsations, lifts, heaves
15. Aortic and pulmonic areas
16. Tricuspid areas
17. Apical area (. Locate point of maximal impulse)
18. Auscultate the aortic, pulmonic, tricuspid and apical valves
Carotid arteries
19. Palpate carotid artery with extreme caution
20. Auscultate the carotid arteries
Jugular veins
21. Inspect jugular veins
Breast and axillae
22. Inspect breast for size, symmetry, contour, or shape while the client is in sitting position
23. Inspect the skin of the brest for localized discolorations or hyper pigmentation, retraction, dimpling, localized hypervascular areas, swelling, or edema
24. Inspect the areola for size, shape, symmetry, color, surface characteristics, and any mass or lesions
25. Inspect the nipples for size, shape, position, color, discharge, and lesions
26. Palpate the axillary, subclavicular and supraclavicular lymph nodes
27. Palpate for breast for masses, tenderness
28. Palpate nipples for tenderness and discharges
Abdomen
29. Inspect the abdomen for skin integrity
30. Inspect the abdominal contour (profile line from rib margin to the pubic bone) while standing at the client’s side while the client is in dorsal recumbent position
31. Inspect for an enlarged liver or spleen
32. Assess the symmetry of contour while standing at the foot of the bed
33. Inspect the abdominal movements associated with respirations, peristalsis, or aortic pulsations
34. Observe vascular patterns
35. Auscultate the abdomen for bowel sounds, vascular sounds, and peritoneal friction rubs
36. Percuss several areas in each of the four quadrants
37. Perform light palpation followed by deep palpation of all four quadrants
Female Genitalia
38. Inspect external female genitalia
39. Observe the labial folds
40. Insert gloved hand and locate the cervix
41. With the use of a vaginal speculum, observe position, color and epithelial surface. Observe for any discharge or bleeding
42. Inspect vaginal mucosa as you withdraw the speculum
Male Genitalia
43. Inspect the penis
44.Palpate the shaft
45. Inspect the scrotum
46. Palpate the scrotums for lumps and tenderness
46. Inspect the inguinal and femoral areas for hernias
47. Palpate the inguinal ring through the scrotal ring ask patient to bear down
Musculoskeletal System
Muscles
48. Inspect the muscles for size. Compare the muscles on one side of the body (arm, thigh, calf) to the same muscle on the other side
49. Inspect the muscle and tendons for contractures (shortening)
50. Inspect the muscles for fasciculations and tremors. Inspect any tremors of the hands and arms out in front of the body
51. Palpate muscle tonicity
52. Test for strength (neck)
53. Test for strength (upper extremities)
54. Test for strength (lower extremities)
Bones
55. Inspect the skeleton for normal structure and deformities
56. Palpate the bones to locate any areas of edema or tenderness
Joints
57. Inspect the joint for swelling
58. Palpate each joint for tenderness, smoothness of movement, swelling, crepitation, and presence of nodule
59. Assess range of motion
60. Upper extremities
61. Lower extremities

CRANIAL NERVES
62. CN I ( Olfactory)
63. CN II (Optic)
64. CN II, III (Optic and occulomotor)
65. CN III, IV,VI ( Occulomotor, trochlear, abducens)
66. CN V (Trigeminal)
67.CN VII (Facial)
68.CN VIII (Acoustic)
69.CN IX, X (Glossopharyngeal and vagus)
70.CN XI (Spinal accessory)
71.CN XII (Hypoglossal)
REFLEXES
72. Assess Upper extremity reflexes ( biceps/triceps/supinator)
73. Assess Lower extremity reflexes (patellar, ankle, Plantar)

Actual score x 100

Total number of items

______________________________ __________________

Faculty (Signature over printed name) Student’s signature