AUGUSTA UNIVERSITY
COLLEGE OF NURSING
PHYSICAL ASSESSMENT PERFORMANCE EVALUATION
NURS 6700
https://augustauniversity.app.box.com/s/r18hveg3b115do5qgxpbl4yg06s66chj
This checklist will be used as the criteria for your Physical Assessment Final Performance Evaluation.
The time allotted for this exercise is 30 minutes. You are expected to interact with your partner as you would
with a patient in that you should explain what you are doing and why. You do not have to follow this exact
sequence. You are also expected to be able to answer basic questions posed by the evaluator throughout the
process.
During the final performance evaluation, you will complete a full head to toe examination. Grading will be based
on points earned out of 100 total points possible.
The physical assessment performance evaluation activity counts as 5% toward your NURS 6700 course grade.
The follow-up documentation evaluation will count as an additional 5% toward your grade for a total of 10% for
Physical Assessment Evaluation.
A REMEDIATION grade will be issued for omitting any major section(s), failure to achieve 85% or above,
lack of preparation, or inability to answer the evaluator’s questions.
Anyone remediated will have one (1) opportunity to re-do the check-off. A grade of 90% or higher must be
achieved on the second attempt. For rechecks, the initial and remediation grades will be averaged for the final
physical assessment performance grade.
NAME:
DATE:
General (5 points)
--performs hand hygiene
--explains procedures and supports patient
--provides privacy
--Identifies patient with 2 identifiers
Organization (5 points)
--assembles all equipment prior to beginning exam
--proceeds in orderly fashion, avoiding frequent position changes
--completes exam in allotted time
Knowledge of Assessment Techniques (5 points)
--in the proper sequence, correctly performs inspection, palpation, percussion, and auscultation
--correctly performs special techniques
Vital Signs (3 points)
--student asks faculty evaluator to provide VS values
--student identifies all typical VS results (i.e. tachycardia, oxygen desaturation, hypertension, etc.)
--student explains possible causative associated factors with reasonable rationale
You may take up to five (5) minutes and jot down anything you choose on a blank piece of paper (no
notes, books, or any other resources permitted). If you want to exercise this option, the clock is ticking.
T
P
R
BP
Pain
/
SpO2
Ht/Wt
P = Provocation/Palliation
Q = Quality/Quantity
R = Region/Radiation
S = Severity Scale
T = Timing
/
BMI
Skin, Hair, and Nails (5 points)
Inspect
general appearance
color
pigmentation
ecchymosis
hair distribution
Ch 13
Documentation Page 221
Inspect & Palpate
texture
lesions
temperature, moisture
mobility/turgor
nails
Head & Neck (5 points)
Inspect
skull, facial symmetry
head size, shape
Ch14
Page 262 Documentation
Inspect & Palpate
skull (tenderness, lumps, depressions)
scalp (tenderness, lesions, hair distribution, hair texture, surface characteristics)
thyroid (size, shape, enlargement)
trachea (position, movement)
lymph nodes (location, size, consistency, mobility, tenderness, warmth)
head (occipital, posterior auricular, preauricular, submandibular, submental)
neck (jugulodigastric, superficial cervical, deep cervical chain, supraclavicular)
TMJ (movement, tenderness, clicks, swelling)
Nose & Sinuses (4 points)
Inspect
septum (location, deviation)
mucosa (color, swelling, tenderness, discharge)
nails
Inspect & Palpate
nasal patency
frontal and maxillary sinuses
Ch17
Page 365 Documentation
Ch17
Page 365 Documentation
Mouth & Throat (4 points)
Inspect
external (lips)
internal (teeth, gums, buccal mucosa), pharynx (tonsils, uvula, phonation)
Inspect & Palpate
tongue (movement, strength, symmetry)
teeth (tap)
Ears (6 points)
Hearing
whisper
Inspect
alignment and symmetry of auricles

mastoid (size, shape, symmetry, position, deformities, lesions)

piercings
Ch16
Page 332 Documentation
Inspect & Palpate
auricles & auditory canal (tenderness, swelling, color, cerumen, lesions)
tragus/external canal (discharge, tenderness)
Otoscopic Exam
tympanic membrane (color)
landmarks (names and describes)
contour
Eyes (6 points)
Inspect
alignment & position
external structures (brows, lids, lashes, symmetry, discharge, swelling)

lesions/nodules
ocular structures (pupils, sclera, conjunctiva)
EOMs
Inspect & Palpate
lacrimal structures (tenderness, redness, discharge)
Red reflex (ophthalmic exam)
Visual acuity
Snellen or Rosenbaum (pocket vision chart)
Cardiovascular (7 points)
Inspect & Palpate
precordium (contour, pulsations, lifts, heaves, thrills)
PMI
Auscultation – Locate Angle of Louis prior to auscultation
 aortic
pulmonic
Erb’s point
tricuspid
mitral
rate, rhythm, any extra sounds
Ch15
Page 302 Documentation
Ch20
Page 482 Documentation
Peripheral Vascular (8 points)
Inspect

skin (color, varicosities)
JVD
Inspect & Palpate
extremities (temperature, moisture, edema, capillary refill)
pulses (temporal, carotid, brachial, radial, popliteal, dorsalis pedis, poster
describe pulse amplitude 0-3) Some agencies use 4-point scale;
Ch 21
Documentation 519
three-point scale:
3+—Full, bounding
2+—Normal
1+—Weak, thready
0—Absent
Auscultate
carotid bruits
Respiratory (7 points)
Inspect
effort to breathe, rate & rhythm
symmetry
Palpate – Anteriorly and posteriorly as appropriate
thoracic expansion (symmetry)

tenderness, tactile fremitus
Ch 19 Documentation 430
Auscultate
general sounds, adventitious sounds (location & description)
vesicular (location & description)
bronchovesicular (location & description)
bronchial/tracheal (location & description)
Abdomen (6 points)
Inspect
skin (scars, color, rashes, bruises, striae), symmetry, contour
venous network
muscles
umbilicus
Auscultate
bowel sounds
bruits:
aortic
renal
iliac
femoral
Percuss
general abdominal sounds
Palpate
 light
 deep (masses, tenderness, rebound, guarding)
 liver
 spleen
Ch 22
Documentation 556
Neurological (12 points)
Orientation
person, place, and time
Ch 24
Documentation 667
Cranial Nerves
olfactory (smell), verbalized, not tested during check offs
optic (visual acuity, peripheral vision)
oculomotor (EOMs, pupils)
trochlear (EOMs, pupils)
trigeminal (facial sensation, muscle strength when teeth clenched, corneal reflex)
abducens (EOMs, pupils)
facial (facial expressions)
acoustic (hearing)
CN page 631
glossopharyngeal (gag reflex, swallow, speech)
vagus (gag reflex, swallow, speech)
spinal accessory (shrug shoulders against resistance)
hypoglossal (tongue strength, position, movement)
Motor

DTRs (biceps, triceps, brachioradialis, patellar, Achilles, plantar),
Babinski
grips
Cerebellar

Romberg (balance)
Gait (tandem walk)
Sensory/Coordination Skills
Peripheral sensation (sharp/dull, temperature, light touch)
Rapid alternating movements
Musculoskeletal (12 points)
Inspect
posture
alignment (symmetry, gross deformities)
gait (rhythm, symmetry)
Ch 23 page 609
Active ROM – Palpate: note tenderness, swelling, palpate crepitus
shoulders
elbow
hands & wrists
spine
hip
knee
feet & ankles
5 =Full ROM against gravity, full resistance
Muscle strength – Describe level 0-5 strength
neck
shoulders
elbow
hands & wrist
hip
knee
feet & ankle
4 =Full ROM against gravity, some resistance
3 = Full ROM with gravity
2 =Full ROM with gravity eliminated (passive motion)
1 =Slight contraction
0 =No contraction
Final grade %:
Recorded out of possible points
/
100
Additional Faculty Comments:
Faculty Signature:
If time <30 minutes… Ask-a-partner— your partner may remind you of the general area that has been omitted, but may not tell you how to
perform the assessment.
Revised 89/2019 JC