NUR 190 Physical Assessment Check-off
15-minute Head-to-Toe Assessment
Student name: ______________________________ Partner: ___________________________________
Date: ______________
Score: _______/50
***There is a 15-minute time limit for completing check off, so practice with a timer until you are proficient.
Head & cranial nerves
Infection control /hand hygiene
Patient identification & allergies
Assess orientation (person, place, time, & event)
Vital signs completed prior to check off- report abnormal,
otherwise state stable
Assess mood & general well being
Assess pain (OLDCART/ICE if pain)
Assess hair & general skin integrity, color, warmth, & edema.
Any scars, lesions?
Inspect ears- state findings
Inspect nose & mouth- state findings
Inspect & palpate neck, trachea & thyroid- state findings
Lymph node palpation- state findings
Auscultate carotid arteries for bruits
Palpate carotid pulses- one at a time & compare with apical
pulse
Assess JVD in neck
Test olfactory (CN I)
Vision exam (CN II) Snellen chart completed prior to check off
Eye: PERRLA (CN III, IV & VI)
Eye: 6 Cardinal fields of gaze (CN III, IV & VI)
Test facial nerves & TMJ (CN V & VII)
Perform whisper test & Romberg test (VIII)
Test tongue movement (CN IX, X, XII)
Test trapezius muscle (CN XI)
Assess gait & balance
Assess upper cerebellar: Perform rapid alternating movements
Assess lower cerebellar: Perform heel -shin
Revised 1/2020 EH
1 pt.
½ pt
0 pt
Comments
Revised 1/2020 EH
Chest & Arms
1 pt.
½ pt
0 pt
Comments
1 pt.
½ pt
0 pt
Comments
Assess skin integrity, color, turgor, warmth, & edema,
sensation. Any scars, lesions?
Inspect thoracic cage for symmetry, muscle development, &
configuration
Palpate symmetric respiratory expansion
Assess brachial, and radial pulses for symmetry
Muscle strength and Joint ROM bilaterally
Assess deep tendon reflex: triceps, biceps, brachioradialis,
patellar
Capillary refill bilaterally
Auscultate with diaphragm (state landmarks, S1 & S2 sounds)
Assess heart and lung sounds on bare skin
Auscultate aortic valve (2nd intercostal, right sternal border),
S2 > S1
Auscultate pulmonic valve (2nd intercostal space, left sternal
border), S2 > S1
Auscultate Erb’s point (3rd intercostal space, left sternal
border), S1 = S2
Auscultate tricuspid valve (4th intercostal space, left sternal
border), S1 > S2
Revised 1/2020 EH
Auscultate mitral valve (5th intercostal space, left midclavicular
line), S1 > S2
Auscultates apical heart rate with patient leaning forward
(state rate & would count for a full minute)
Verbalizes respiratory effort (pattern/rhythm)
Auscultate posterior breath sounds
Auscultate lateral breath sounds
Auscultate anterior breath sounds
Revised 1/2020 EH
Revised 1/2020 EH
Abdomen
1 pt.
½ pt
0 pt
Comments
1 pt.
½ pt
0 pt
Comments
Ask about bowel and bladder, color, consistency, S/Sx UTI?
Abdominal inspection- Any scars, lesions, hernias, ascites?
state findings
Abdominal auscultation, in all 4 quadrants &
abdominal arteries for bruits- state findings
Lower Extremities
Assess skin integrity, color, warmth, Any edema, varicosities,
scars, lesions?
BLE strength and joint ROM
Assess deep tendon reflex: Patellar
Pulses: posterior tibialis, dorsalis pedis,
Capillary refill bilaterally
Revised 1/2020 EH