ARIZONA COLLEGE SCHOOL OF NURSING
LAS VEGAS CAMPUS
FINAL COMPREHENSIVE PHYSICAL ASSESSMENT EVALUATION
Gather all equipment needed prior to your assessment and clean as needed. Students
should bring the following items for assessment.
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Name badge/Dress code/hair
Stethoscope
Black Ink pen
Pen light
Physical examination/assessment
General Skills/ Subjective data
 Introduction
 Hand Hygiene
 Identify patient
 Provide privacy
 Check allergies
 A/O x 3
 Observe for any monitors, IV tubing, O2, drains and tubes attached to the patient.
 Chief complaint/ or reason for visit
 Past medical/surgical history
 Medication history
 Explain procedure
 Place bed at a comfortable level
 Make patient comfortable
 Organization skills
 Don gloves prior to exam
Vital signs
 Temperature
 Pulse
 Resp
 O2 sats
 BP
 Pain
Scalp/hair
Head, face and cranial nerves
Eyes- PERRLA, position, pupil size, vision (ask if patient wears glasses. Snellen chart if applicable
can be done while you do your ambulation)
Ears- External, any drainage and hearing (able to obey commands) (No otoscope)
Nose- Smell, patency and symmetry (No scope)
Mouth- General appearance, teeth, tongue, uvula,
Perform your cranial nerves and sensation while doing face and head.
Neck
 Mass
 Trachea midline
 Lymph nodes/ thyroid
 ROM
 Skin
 JVD/Carotid artery bruits
Chest
 Symmetry
 Skin
 Auscultate lungs Anterior
 Auscultate heart sounds and apical pulse
 Lateral lung sounds
 Posterior lung sounds
 Check spine for any abnormalities that are visible and skin on back.
Abdomen
 Bowel movement and urination
 Inspection
 Auscultation (4 quadrants)
 Light palpation
 Deep palpation (Verbalize)
 Abdominal aorta for bruit or pulsation
Upper Extremity
 Skin
 Edema
 Bilateral radial pulses
 Cap refill
 Clubbing
 Strength
 ROM
 Neuro check
Lower Extremity
 Skin
 Edema
 Foot examination
 Pulses
 Cap refill
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Reflexes
Strength
ROM
Neuro check
Complete assessment check for safety issues, place bed in lower position and make
patient comfortable.
Before leaving room ask patient if there is anything else, they need. Remove trash from
bedside.
Perform hand hygiene
and complete documentation