QuestionAnswered step-by-stepDocumentation Assignment PHYSCIAL EXAMINATION Document Assignment: Physical Examination Download Document Assignment: Physical ExaminationStudents will have the opportunity to practice on a peer and/or standardized patient during the second simulation day. You are expected to complete a head-to-toe assessment on a classmate during this practice session. Students may utilize the form/rubric below during practice to obtain objective data. This information will be the basis for your physical examination documentation assignment within the course. Helpful hints: During your practice session with your peer, write your findings down. These may be normal and/or abnormal findings. You will need to describe what normal and abnormal mean. For example, instead of documenting “the skin assessment is normal”, you can use descriptors such as “skin is warm, soft, uniform, and appropriate for ethnicity. No evidence of ecchymosis, or lesions.” This allows the grader to understand the things you are assessing. The use of normal will result in point deductions. Do not document things you did not assess! Rubric So what am looking for is a sample documentation of a Physical Head to Toe Exam on a Healthy adult who came in for a wellness check. Documentation Assignment: Physical Exam Criteria Ratings Pts Dermatology Skin Assessment: Nail Assessment: Inspects the skin (hands & arms, legs & feet)Assesses skin temperature, tissue integrity and turgor(sternum)Inspects and palpates thefingernails 4 pts Head Hair condition: Scalp condition: Inspects hair and scalpPalpates hair and scalp 4 pts Face Facial Features: Temporomandibular Joint: Assessment of CN V: Assessment of CN VII: Inspects facial features for symmetry 1Palpates the temporomandibular joint as theclient opens and closes the mouthPalpates temporalis and masseter muscles whileclenching the teeth (Cranial nerve V)*Assesses light touch across face(Cranial nerve V) *Asks client to smile, frown, puffout cheeks, raise and lowereyebrows (Cranial nerve VII) 8 pts Eyes Vision: External: Internal: PERRLA (Pupils Equal, Reactive to Light, Accommodation): tests visual acuity (Cranialnerve II)* 2Inspects external eye structures(lids, lashes, brows) 2Inspects internal eye structures(conjunctivae, sclerae) 1Checks pupillary reaction tolight (direct and consensual)and accommodation (Cranialnerve III, IV, VI)* 8 pts Ears External: Hearing (whisper test):Inspects auricles 1Palpates auricles 1Tests hearing acuity (whisperedtest) (Cranial nerve VIII)* 4 pts Nose: External: Internal: Patency: Assessment of CN I:Inspects & palpates externalnoseInspects internal nose, checksfor patency 1Tests ability to smell (Cranialnerve I) 4 pts Mouth: Teeth: Gingival & Buccal Mucosa: Assessment of CN IX/X: Assessment of CN XII: Tonsils: Inspects lips, teeth andgingival, buccal mucosa 1Inspects protruded tongue inmidline (Cranial nerve XII)* 2Assess the pharynx (Mobility ofuvula as the person phonates”ah”) (Cranial nerve IX, X)* 2Assess tonsils 5 pts Neck: Teeth: Gingival & Buccal Mucosa: Assessment of CN IX/X: Assessment of CN XII: Tonsils: Inspects structures of the neck(trachea, symmetry) 1Palpates carotid arteries 1Tests strength of trapezius(Cranial nerve XI) 6 pts Lymphnodes: Names and Assessment: Occipital 0.5Posterior auricular 0.5Pre-auricular 0.5Submandibular 0.5Submental 0.5Superficial cervical 3 pts Range of Motion: Neck: Shoulders: Elbows: Ankles: Spine: Neck: Flexion, hyperextension,lateral bending & lateralrotation (sternocleidomastoid:verbalize Cranial nerve XI)* 3Shoulders: Forward flexion,hyperextension, internalrotation, abduction, adduction,external rotation 3Elbows: Flexion, extension,pronation, supination 2Ankles: Plantar flexion,dorsiflexion, eversion, inversion 2Spine: Flexion,hyperextension, lateralbending, rotation 10 pts Upper Extremities: Radial Pulses: Capillary Refill: Palpates radial pulses 1Assesses capillary refill (fingers) 2 pts Thorax: Appearance: Palpation Findings: Auscultation Findings (anterior/posterior/lateral):Inspects the thorax (posterior, lateral, anterior) with client sitting.Palpates posterior chest wall forchest expansion 1Auscultates breath sounds -posterior chest 2Auscultates breath sounds -anterior chest 2Auscultates breath sounds -lateral chest walls 8 pts Heart: Auscultation Findings (all valve areas):Auscultates heart sounds in allvalve areas using diaphragm ofstethoscope (aortic, pulmonic,tricuspid, mitral) 2Auscultates heart sounds in allvalve areas using bell ofstethoscope (aortic, pulmonic,tricuspid, mitral) 8 pts Abdomen Appearance: Auscultation Findings (4 quadrants): Palpation Findings (4 quadrants):Inspects abdomen 1Auscultates the four quadrantswith diaphragm of stethoscope 2Performs light palpation in thefour quadrants 6 pts Lower Extremities General Appearance and Condition: Dorsalis Pedis: Posterior Tibialis: Edema: Capillary Refill: Palpates posterior tibial pulses 1Palpates dorsalis pedis pulses 1Assess capillary refill (toes) 1Assess for edema 5 pts Sensory Light Touch (arms): Light Touch (legs): Assess light touch using softand sharp (on arms and legs) 2 pts Cerebellar Gait: Romberg: Gait: normal (toward & away)and tandem (heel-to-toe) 2Romberg Test 2 pts Deep Tendon Reflexes Patellar: 1 pts Format Spelling (3) Appropriate Use of Medical Terminology (3) Attention to bilateral findings (4) 10 pts Total Points: 100Health ScienceScienceNursingNURS MISCShare Question
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