NR 509 Immersion Physical Assessment Study Guide
NR 509 Immersion – Physical Assessment Steps
1) Greet patient
2) Inspect face – no discoloration
... [Show More] or lesions present
3) Inspect head – midline, symmetrical
4) Palpate lymph nodes:
• Preauricular
• Postauricular
• Occipital
• Tonsillar
• Submandibular
• Submental
• Anterior cervical
• Posterior cervical
• Supraclavicular
*No enlargement, equal bilaterally.
5) Cranial nerve #5 (TRIGEMINAL)
• Motor: palpate masseter muscle and have patient clench teeth
-no distortions, great strength
• Sensory: have patient close eyes and touch face with q-tip, have them verbalize where on face you are touching
- Pt. verbalized appropriate areas that were touched. Cranial nerve # 5 is intact.
6) Cranial nerve # 7 (FACIAL)
• Facial expressions: smile, frown, puff cheeks—symmetric and equal bilaterally, pucker lips—tight
7) Inspect ears—no nodules or skin lesions present, symmetrical
• Use otoscope to inspect external auditory canal. Pull ear up and back.
- No swelling, redness, drainage or cerumen.
-Tympanic membrane is pearly gray, no effusion present in middle ear.
*Repeat on other side.
• Palpate pinnae & tragus - no nodules or tenderness
8) Cranial nerve # 8 (ACOUSTIC)
• Whisper test
- Have patient cover one ear
- Whisper 3 words
- Repeat on other side
*Hearing intact bilaterally.
9) Inspect eyes—conjunctiva clear and pink, no drainage or lesions present; sclera white and
clear.
10) Cranial nerve #2 (OPTIC)
• Snellen eye chart—tests central vision
-Stand 6 feet away from patient.
-Have patient cover 1 eye and read smallest line.
-Repeat with other eye.
-Repeat with both eyes.
*Report as 20/20 vision in R eye, L eye, and both eyes.
• Continuing assessment of cranial nerve # 2—test peripheral vision.
- Stand at eye level with patient and have patient look straight ahead.
- Test peripheral vision from behind shoulders, above head, and from below at
waist.
• Continuing assessment of cranial nerve # 2—test pupillary response.
- Use light on ophthalmoscope and ask patient to stare at your nose.
- Come from side of eye to front.
• Both pupils constrict, 2 to 3 cm in diameter, respond to light.
11) Cranial nerves #3 (OCULOMOTOR), #4 (TROCHLEAR), & #6 (ABDUCENS)
• Star or “H” pattern—checking extraocular muscles of the eye
• All extraocular movements are intact equally.
12) Inspect nose—midline, no obstructions, swelling or visible fractures
- Use otoscope— tip nose up with thumb.
• Inspect left turbinate—pink & moist
• Angle inward to inspect septum—midline, no swelling or bogginess
• Repeat on other side.
13) Palpate frontal and maxillary sinuses—assess for tenderness
14) Inspect throat and mouth:
• Lips—pink and moist
• Open mouth:
- Inspect teeth—no signs of decay or cracks
- Inspect gums—pink and healthy, no redness or swelling
- Inspect buccal mucosa—pink and moist
- Inspect palate—hard & soft palates healthy, pink and moist
- Inspect tongue— smooth, healthy, pink and moist
*Lift tongue:
- Inspect floor of mouth—no nodules or drainage, healthy, pink and moist
- Inspect posterior pharynx—healthy pink, no postnasal drainage, grade tonsils if present (2 + is normal)
15) Cranial nerve #9 (GLOSSOPHARYNGEAL)
• Tests gag reflex—WILL NOT BE PERFORMING FOR THIS EXAM
16) Cranial nerve #10 (VAGUS)
• Use light source:
- Have patient open mouth and say “Ahh” - note uvula moves up and is
symmetrical with phonation
17) Cranial nerve #12 (HYPOGLOSSAL)
• Have patient stick out tongue and move side to side—normal, no restrictions or deviations
18) Palpate TMJ (temporomandibular joint)
• Palpate both sides at same time. Have patient open and close mouth.
- Checking for any subluxations, tenderness, clicks or crepitus– none present
19) Inspect neck—symmetrical, no obvious deformities
• Palpate trachea—midline, no abnormalities
• Palpate thyroid gland:
- Find cricoid process w/ 1 hand & suprasternal notch with other hand.
- Palpate in between these two points.
- Retract one side and ask patient to swallow.
- Feel thyroid—no nodules, normal in size.
* Repeat on other side.
20) Palpate carotid arteries (side of trachea) — normal and bounding
• Auscultate carotid arteries—use bell of stethoscope!
- Have patient take a breath and hold it—no bruits noted
*Repeat on other side.
21) Range of motion—NECK
• Drop chin to chest (checking flexion)
• Look up (checking extension)
• Look over R shoulder, then L shoulder (checking rotation)
• Ear to shoulder—both sides (checking lateral flexion)
*All movements intact equally
22) Cranial nerve #11 (SPINAL ACCESSORY)
• Place hands on patient’s shoulders, have them shrug against resistance—equal and intact bilaterally
23) Heart sounds—5 areas:
* Auscultate with diaphragm AND bell of stethoscope while patient is sitting down.
1. Aortic valve—2nd intercostal space on R sternal border
2. Pulmonic valve—2nd intercostal space on L sternal border
3. Erbs point—3rd intercostal space on L sternal border
4. Tricuspid valve—4th intercostal space on L sternal border
5. Mitral valve—5th intercostal space @ midclavicular line
24) Inspect anterior chest—assess for any obvious deformities and symmetry—none found
25) Auscultate lung sounds— have patient breathe in and out through mouth
• Anterior (6 areas) —good air movement, clear breath sounds bilaterally
• Posterior (8 areas) —good air movement, clear breath sounds bilaterally
26) Inspect upper extremities
• Inspect joints of hands—checking for redness, swelling, or deformities in joints
• Palpate capillary refill time (CRT) bilaterally—pink in < 3 seconds = normal CRT
• Palpate radial pulses (@ same time) — 2+, equal bilaterally
• Check hand grip strength (@ same time) —strength 5/5 bilaterally
27) Assess ROM (*Normally assess bilaterally but for immersion only assess unilaterally)
• Passive ROM in elbow—perform flexion and extension
• Check strength of biceps & triceps
- Flex elbows & push against hands, then have patient pull against your hands—
bicep and tricep strength is 5/5
• Passive ROM in shoulder— perform flexion and extension
- Internal and external rotation
- Abduction and adduction
28) Cerebellar coordination
• Rapid alternating movements:
- Touch fingers to thumbs (bilaterally @ same time) — well-coordinated
- Alternate hitting palms and back of hands on thighs—well-coordinated
29) Deep tendon reflexes (only evaluate unilaterally for immersion)
• Bicep tendon:
- Support patient’s arm on your arm
- Place thumb on medial aspect of antecubital fossa
- Strike thumb w/ pointy end of reflex hammer
* Bicep tendon contracts = normal response
• Patellar tendon:
- Strike below knee cap w/ flat end of hammer—normal response noted
• Achilles tendon:
- Relax foot and dorsiflex foot, tap w/ flat end of hammer—normal pronation
30) Abdominal exam
• Expose abdomen—observe for contour, symmetry and distortions.
• Auscultate bowel sounds in all 4 quadrants.
• Auscultate abdominal arteries for bruits w/ bell of stethoscope
a. Aortic area (below zyphoid process @ midline)
b. L renal (above and lateral to left of umbilicus)
c. R renal (above and lateral to right of umbilicus
d. L iliac (below and lateral to left of umbilicus)
e. R iliac (below and lateral to right of umbilicus)
*No bruits noted
31) Percuss all 4 quadrants: checking for tympany, dullness, or flatness—normal
33) Palpate all 4 quadrants (had over hand, circular motion)
• Assess for tenderness or palpable masses—no tenderness or masses present
34) Palpate liver:
- place hand under patient w/ palm up (costovertebral angle), look @ midclavicular line and press down and upward while instructing patient to take a deep breath in—
feeling for lower edge of liver
35) Palpate spleen:
- Have patient turn onto right side
- Place hand under patient w/ palm up (costovertebral angle)
- Press down and upward while instructing patient to take a deep breath in— do not
feel edge of spleen = normal finding
36) Test Bloomberg sign:
• Hand at 90° - press down on RLQ—rebound tenderness = positive Bloomberg sign
* Repeat on LLQ
37) Inspect lower extremities—no edema or lesions noted
38) Range of motion—HIP
• Flex knee & push up to flex hip
• Abduction (away)
• Adduction (cross midline over other leg)
• Internal rotation (knee in, ankle out)
• External rotation )knee out, ankle in)
* Good range of motion
* Rest leg—will not be testing extension.
39) Range of motion—KNEE
• Perform flexion and extension
• Test strength of knees (bilaterally @ same time)
- Flex knee, place hands on patient’s shins.
- Ask pt. to push up against hands
- Place hands on calves, ask pt. to push down against hands
* Good strength, 5/5 and equal bilaterally
40) Range of motion—ANKLE
• Support ankle to check for flexion, extension, & rotation
- Check dorsiflexion (toward head)
- Check plantarflexion (toward ground)
- Check rotation (move ankle in a circle)
* Good range of motion
• Test strength of ankles (bilaterally @ same time)
- Dorsiflex w/ resistance
- Plantarflex w/ resistance
* Good strength, 5/5 and equal bilaterally
41) Palpate dorsalis pedis pulses—2+ and equal bilaterally
42) Spine exam (have patient stand up)
• Inspect and palpate along each side of spine—assess for any curvatures, malalignment or tenderness
• ROM—spine:
- Bend over and touch toes, then stand up straight
- Bend backward, then straighten back up
- Lateral flexion to each side
- Rotation to each side
* Good active ROM
43) Romberg’s test:
• Stand w/ arms down to side.
• Close eyes for ~ 20 seconds.
-Assess for any swaying—Romberg’s test is NEGATIVE if no swaying is seen
44) Gait:
• Have patient take a few steps away from you and then walk back
- Note any abnormalities in gait.
* Patient has normal gait [Show Less]