Adult Physical Assessment Practice Tool

NU2ICU V3 logoADULT PHYSICAL ASSESSMENT PRACTICE TOOL

These pages titled Adult Physical Assessment Practice Tool are all about what we set out to achieve when we wrote and you accessed this site.  To assist in empowering you with the skills and knowledge to perform a high quality bedside patient assessment

To feel comfortable in your new ICU environment by being able to have a strong foundation of “what I’m looking for”

All the clues are there in the assessment text and your chosen supervisor can help by giving you hints if asked, so be clear, be strong and good luck

 Print this area and start to practice because your assessment begins now!

NU2ICU

 

PATIENT’S INITIALS                                                               ASSESSEE’S INITIALS                                                              SUPERVISOR’S INITIALS                                                                         DATE

ASSESSMENT

Summary / Comments

Assessee performs “ABCDE Algorithm” to assess for immediate patient safety and ability to continue assessment
Performs hand hygiene, introduces self, explains procedure, establishes understanding,  obtains required consent, provides privacy

Reviews patient’s record & chart (inc medications)

 
Re- performs hand hygiene / apply PPE as indicated  
Assesses patients understanding of reason for admission

– what event brought them to hospital

 
Assesses client’s pain level and give analgesia if appropriate

– ask on score of 0 – 10

– can they comfortably deep breath & cough (watch visual clues, increased BP / HR etc)

 
Assesses the overall appearance of the patient

– mental status, mood / affect and general hygiene.

 
Assesses the Glascow Coma Score

 

Eyes                   / 4
Verbal               / 5
Motor                / 6
TOTAL               / 15
Assesses for any limitations / deficits to client’s hearing or sight
Assesses any changes in vision, hearing, smell & taste

– Pupils L = R and size

– This quickly assesses cranial nerves and investigate & evaluate further if any abnormalities

 

 

Obtains baseline vital signs (Resp, SaO2, HR & temp)

– review ABG if present

– fluid balance

 
Uses a manual sphygmomanometer to assess BP and calculates MAP*  
Assesses CVP / JVP if present  
Assesses amount and delivery method of supplemental O2 if any  
Assesses patient’s tongue

–     moistness

–     pink (no cyanosis)

–    midline

 
Assesses upper extremities

– inspect skin color

– nail bed angles*

– capillary refill

– turgor

– oedema

– temperature and moisture (compare central to peripheral temp)

 
Assesses upper motor skills

–     L = R

–    strength of pull and push shoulders, arms & handgrip

 

 

Inspects chest for symmetry & gross anomalies

–     bruising,

–     swelling

–     subcutaneous emphysema

 

 

Assesses presence of cough and productivity

–     colour

–     amount

–    thickness of phelm

 
Auscultates lung sounds anterior and lateral

– correlate for signs of COPD

– stridor

– crackles

– L = R

 

 

Reviews CXR if available

–     compare to previous if available

 
Assesses cardiac rhythm

–     review ECG if avail

–    compare apex to radial

 
Assesses heart sounds (4 places with bell and diaphragm)  
Inspects abdomen

– bruising

– swelling

– distension/ tightness

– presence of NE/NG tube

– level of residual feeds

– when bowel last open

 

 

Auscultates 4 quadrants of abdomen

– quality and presence of sounds

– if patient can eat do they have a diet arranged / ordered

 

 

Assesses groin area

– IDC

– urine output

– colour

– skin integrity / thrush

– catheter security

 

 

Assesses lower extremities

– inspect skin color

– capillary refill

– turgor

– oedema / calf swelling

– temperature and moisture

 

 

Assesses peripheral pulses (PT & DP)

– L = R

Assesses lower motor skills

L = R

– strength & flexion / extension / adduction / abduction

 
Assesses back and buttocks (assess if able to be safely rolled)

– inspect  skin color

– integrity / breakdown

– trace spine downwards to assess for pain / anomalies

– oedema

– temperature and moisture

 
Assesses any wounds, stomas, surgical incisions

– colour

– temperature

– function of stoma

– signs of infection

– quality / frequency of dressing if any

– jelco(s) in date or removed if unnecessary

 

 

ALL CENTRAL VENOUS CATHETERS (CVC / PICC)

– CVC infusion lines identified and labeled clearly

– secured with a stich (if CVC)

– dressing clean

– line free of air / blood

– insertion site infection state / CVC still required?

 

 

Assesses all lines

– labeled to standard

– in date

 
Obtain / check Blood Glucose Level

– between 5 – 9.9

 
Discussed with patient psychosocial needs

– family / friend support at home if required

– pre-existing use of support networks

– pastoral care visit required

– referrals to social work etc

 
Assesses safety issues

– allergies and effect on lifestyle

– history of falls

– changes in diet

– changes in medication

– effect of current issues

 

 

Gave opportunity for patient to ask questions if able, answered as able  
Assessed patient remains comfortable and is safe to be left  
Disposed of PPE / perform hand hygiene  
Reflection of findings / recommendations to supervising RN

– discuss follow ups required post assessment

– any changes in frequency or type of assessments

 
Document findings appropriately  

Your assessment summary comments

 

Your assessment recommendations

 

Feedback RN initials

 Assessment feedback  (Refer to previous pages if staging needed)                 Date 

 

Feedback RN comments (if any)


 

More reading

NU2ICU GENERAL ASSESSMENT

NU2ICU PRIMARY ASSESSMENT

NU2ICU SECONDARY ASSESSMENT

NU2ICU KNOWLEDGE ADJUNCTS

NU2ICU AUSCULTATION SKILLS

NU2ICU NORMAL VALUES

NU2ICU RRS / MET VALUES