Return Demonstration – Mastery Test

Biographic Data
Nursing Interview Guide to Collect Subjective Data from the Client Data
1. Name?
2. Address?
3. Phone?
4. Birthdate?
5. Provider history?
6. Ethnicity?
7. Educational level?
8. Occupation?
Current Symptoms
1. History of present concern (COLDSPA)
Past History
1. Birth problems?
2. Childhood illnesses?
3. Immunizations?
4. Illnesses?
5. Surgeries?
6. Accidents?
7. Pain?
8. Allergies?
Family History
1. Family genogram?
Physical Assessment Guide to Collect Objective Client Data
Questions
1. Gather all equipment needed for a head-to-toe exam
2. Prepare client by explaining what you will be doing
General survey
1. Observe appearance.
2. Assess vital Signs.
3. Take body measurements
4. Calculate deal body weight. body mass index. waist-to-hip ratio. mid-
arm muscle area and circumference.
5. Test vision
Head and Face
1. Inspect and palpate head.
2. Note consistency. distribution. color of hair.
3. Observe face for symmetry, features, expressions, condition of skin.
4. Have the client smile. frown, show teeth, blow out cheeks, raise
eyebrows, and tightly close eyes (CN VII).
5. Test sensations of forehead, cheeks, and chin (CN V).
6. Palpate temporal arteries for elasticity and tenderness.
7. Palpate temporomandibular joint.
Eyes
1. Assess visual function.
2. Inspect external eye.
3. Test papillary reaction to light.
4. Test accommodation of pupils.
5. Assess corneal reflex (CN VII facial).
6. Use an ophthalmoscope to inspect the interior of the eye.
Ears
1. Inspect auricle, tragus, and lobule.
2. Palpate auricle and mastoid process.
3. Use otoscope to inspect auditory canal.
4. Use otoscope to inspect tympanic membrane.
5. Test hearing.
Nose and Sinuses
1. Inspect external nose.
2. Palpate external nose for tenderness.
3. Check patency of airflow through nostrils.
4. Occlude each nostril and ask client to smell for soap. coffee, Or vanilla
(CN I).
5. Use an otoscope to inspect internal nose.
6. Transilluminate maxillary sinuses.
Mouth and throat.
1. Put on gloves
2. Inspect lips.
3. Inspect teeth.
4. Check gums and buccal mucosa.
5. Inspect hard and soft palates
6. Observe uvula
7. Assess for gag reflex (CN X).
8. Inspect tonsils.
9. Inspect and palpate tongue.
I2. Assess tongue strength (CN IX and X).
11. Check taste sensation (CN VII and IX).
Neck
1. Inspect appearance of neck.
2. Test ROM of neck.
3. Palpate preauricular, postauricular, occipital, tonsillar, submandibular,
and submental nodes.
4. Palpate trachea
5. Palpate thyroid gland.
6. If enlarged. auscultate thyroid gland for bruits.
7. Palpate and auscultate carotid arteries
Arms, Hands, and fingers
1. Inspect upper extremities.
2. Test shoulder shrug and ability to turn head against resistance (CN XI
spinal).
3. Palpate arms.
4. Assess epitrochlear lymph nodes.
5. Test ROM Of elbows.
6. Palpate brachial pulse.
7. Palpate ulnar and radial pulses.
8. Test ROM of wrist.
9. Inspect and palpate palms of hands. I0. Test ROM of fingers.
11. Use reflex hammer to test biceps, triceps. And brachioradialis reflexes.
12. Test rapid alternating movements of hands.
13. Test sensation in arms. hands, and fingers and Lateral Chest
Posterior and Lateral Chest
1. Ask the client to continue sitting with arms at sides and stand behind
the client. Untie gown to expose posterior chest.
2. Inspect scapulae and chest wall.
3. Note the use of accessory muscles when breathing.
4. Palpate chest.
5. Evaluate chest expansion at T9 or TIO.
6. Percuss at posterior intercostal spaces
7. Determine diaphragmatic excursion.
8. Auscultate posterior chest.
9. Test for two-pant discrimination on back.
I0. Auscultate apex and left sternal border of heart during exhalation.
Anterior Chest
1. Inspect chest.
2. Note quality and pattern of respiration.
3. Observe intercostal spaces.
4. Palpate anterior chest
5. Percuss anterior chest.
6. Auscultate anterior chest.
7. Test skin mobility and turgor.
8. Ask client to fold gown to waist and with arms hanging freely
Female Breasts
1. Inspect both breasts, areolas. and nipples
2. Inspect for retractions and dimpling of nipples
Male Breasts
1. Inspect breast tissue
2. Palpate breast tissue and axillae.
3. Assist client to supine position with the head elevated to 30 to 45
degrees. Stand on client’s right side.
Neck
1. Evaluate jugular venous pressure.
2. Assist client to supine position (lower examination table)
Female Breast
1. Palpate breasts for masses and nipples for discharge.
2. Teach breast self-examination.
Heart
1. Inspect and palpate for apical impulse.
2. Palpate the apex, left sternal border. and base of the heart.
3. Auscultate over aortic area, pulmonic area. Erb point, tricuspid area.
and apex.
4. Auscultate apex of heart as client lays on left side.
Abdomen
1. Cover chest with gown and arrange draping to expose abdomen.
2. Inspect abdomen
3. Auscultate abdomen.
4. Percuss abdomen
5. Palpate abdomen.
Legs, Feet, and Toes
1. Observe muscles.
2. Note hair distribution.
3. Palpate joints of hips and test ROM.
4. Palpate legs and feet.
5. Palpate knees.
6. Palpate ankles
7. Assess capillary refill.
8. Test sensations (dull and Sharp), two-point discrimination. reflexes.
position sense, and vibratory sensation.
9. Perform heel-to-shin test.
10. Perform any special tests as warranted
11. Secure gown and assist client to standing position.
Musculoskeletal and Neurologic Systems
1. Observe for spinal curvatures and check for scoliosis.
2. Observe gait.
3. Observe tandem walk.
4. Observe hopping on each leg.
5. Perform Romberg test.
6. Perform finger-to-nose test.
Comprehensive Nursing Interview and Physical Assessment Guide

Biographic Data Collection

1. Name?

2. Address?

3. Phone?

4. Birthdate?

5. Provider History? (Previous healthcare providers, primary care physician)

6. Ethnicity?

7. Educational Level?

8. Occupation?

Current Symptoms

1. History of Present Concern (COLDSPA):

o Character: Describe the symptom.

o Onset: When did it start?

o Location: Where is it located?

o Duration: How long does it last?

o Severity: How bad is it on a scale of 1 to 10?

o Pattern: What makes it better or worse?

o Associated Factors: Any other symptoms accompanying it?

Past History

1. Birth Problems?

2. Childhood Illnesses?

3. Immunizations?

4. Illnesses?

5. Surgeries?

6. Accidents?

7. Pain?

8. Allergies?

Family History
 1. Family Genogram? (A diagram depicting family relationships and health
history)

Physical Assessment Guide to Collect Objective Client Data

Preparation and General Survey

1. Gather all equipment needed for a head-to-toe exam.

2. Prepare client by explaining what you will be doing.

General Survey

1. Observe Appearance: Note overall condition, hygiene, and behavior.

2. Assess Vital Signs: Measure temperature, pulse, respiration, and blood

pressure.

3. Take Body Measurements: Height, weight.

4. Calculate Ideal Body Weight, Body Mass Index (BMI), Waist-to-Hip

Ratio, Mid-Arm Muscle Area, and Circumference.

5. Test Vision: Use Snellen chart or other vision testing tools.

Head and Face

1. Inspect and Palpate Head: Check for shape, size, and any abnormalities.

2. Note Consistency, Distribution, and Color of Hair.

3. Observe Face for Symmetry, Features, Expressions, Condition of Skin.

4. Facial Movements: Have the client smile, frown, show teeth, blow out
cheeks, raise eyebrows, and tightly close eyes (Cranial Nerve VII).

5. Test Sensations: Forehead, cheeks, and chin (Cranial Nerve V).

6. Palpate Temporal Arteries for Elasticity and Tenderness.

7. Palpate Temporomandibular Joint: Check for pain or clicking.

Eyes

1. Assess Visual Function: Test visual acuity.

2. Inspect External Eye: Check eyelids, lashes, and conjunctiva.

3. Test Pupillary Reaction to Light.

4. Test Accommodation of Pupils.

5. Assess Corneal Reflex (Cranial Nerve VII Facial).

6. Use Ophthalmoscope: Inspect interior structures of the eye.

Ears

1. Inspect Auricle, Tragus, and Lobule.

2. Palpate Auricle and Mastoid Process.

3. Use Otoscope: Inspect auditory canal and tympanic membrane.

4. Test Hearing: Use tuning fork (Weber and Rinne tests).

Nose and Sinuses

1. Inspect External Nose: Check for deformities or lesions.

2. Palpate External Nose for Tenderness.

3. Check Patency of Airflow through Nostrils.

4. Olfactory Test: Occlude each nostril and ask the client to smell (Cranial
Nerve I).

5. Use Otoscope: Inspect internal structures.

6. Transilluminate Maxillary Sinuses: Check for fluid or inflammation.

Mouth and Throat

1. Inspect Lips: Look for color, moisture, and lesions.

2. Inspect Teeth: Note number, condition, and alignment.

3. Check Gums and Buccal Mucosa: Look for color and lesions.

4. Inspect Hard and Soft Palates: Look for color and structure.

5. Observe Uvula: Check movement.

6. Assess Gag Reflex (Cranial Nerve X).

7. Inspect Tonsils: Note size and presence of exudate.

8. Inspect and Palpate Tongue: Note texture and lesions.

9. Assess Tongue Strength (Cranial Nerves IX and X).

10.Check Taste Sensation (Cranial Nerves VII and IX).

Neck

1. Inspect Appearance of Neck.

2. Test Range of Motion (ROM).

3. Palpate Lymph Nodes: Preauricular, postauricular, occipital, tonsillar,

submandibular, submental.

4. Palpate Trachea.
 5. Palpate Thyroid Gland: If enlarged, auscultate for bruits.

6. Palpate and Auscultate Carotid Arteries.

Arms, Hands, and Fingers

1. Inspect Upper Extremities.

2. Test Shoulder Shrug and Head Turn Against Resistance (Cranial

Nerve XI).

3. Palpate Arms.

4. Assess Epitrochlear Lymph Nodes.

5. Test ROM of Elbows.

6. Palpate Brachial Pulse.

7. Palpate Ulnar and Radial Pulses.

8. Test ROM of Wrist.

9. Inspect and Palpate Palms of Hands.

10.Test ROM of Fingers.

11.Test Reflexes: Biceps, triceps, brachioradialis.

12.Test Rapid Alternating Movements of Hands.

13.Test Sensation in Arms, Hands, and Fingers.

Posterior and Lateral Chest

1. Inspect Scapulae and Chest Wall.

2. Note Use of Accessory Muscles When Breathing.

3. Palpate Chest.

4. Evaluate Chest Expansion at T9 or T10.

5. Percuss Posterior Intercostal Spaces.

6. Determine Diaphragmatic Excursion.

7. Auscultate Posterior Chest.

8. Test for Two-Point Discrimination on Back.

9. Auscultate Apex and Left Sternal Border of Heart During Exhalation.

Anterior Chest

1. Inspect Chest.
 2. Note Quality and Pattern of Respiration.

3. Observe Intercostal Spaces.

4. Palpate Anterior Chest.

5. Percuss Anterior Chest.

6. Auscultate Anterior Chest.

7. Test Skin Mobility and Turgor.

Female Breasts

1. Inspect Breasts, Areolas, and Nipples.

2. **Inspect for Retractions and D

imping of Nipples**.

Male Breasts

1. Inspect Breast Tissue.

2. Palpate Breast Tissue and Axillae.

3. Assist Client to Supine Position with the Head Elevated to 30 to 45

Degrees.

Neck

1. Evaluate Jugular Venous Pressure.

2. Assist Client to Supine Position (Lower Examination Table).

Female Breast (Continued)

1. Palpate Breasts for Masses and Nipples for Discharge.

2. Teach Breast Self-Examination.

Heart

1. Inspect and Palpate for Apical Impulse.

2. Palpate the Apex, Left Sternal Border, and Base of the Heart.

3. Auscultate Over Aortic Area, Pulmonic Area, Erb's Point, Tricuspid

Area, and Apex.

4. Auscultate Apex of Heart as Client Lays on Left Side.

Abdomen

1. Cover Chest with Gown and Arrange Draping to Expose Abdomen.

2. Inspect Abdomen.
 3. Auscultate Abdomen.

4. Percuss Abdomen.

5. Palpate Abdomen.

Legs, Feet, and Toes

1. Observe Muscles.

2. Note Hair Distribution.

3. Palpate Joints of Hips and Test ROM.

4. Palpate Legs and Feet.

5. Palpate Knees.

6. Palpate Ankles.

7. Assess Capillary Refill.

8. Test Sensations (Dull and Sharp), Two-Point Discrimination,

Reflexes, Position Sense, and Vibratory Sensation.

9. Perform Heel-to-Shin Test.

10.Perform Any Special Tests as Warranted.

11.Secure Gown and Assist Client to Standing Position.

Musculoskeletal and Neurologic Systems

1. Observe for Spinal Curvatures and Check for Scoliosis.

2. Observe Gait.

3. Observe Tandem Walk.

4. Observe Hopping on Each Leg.

5. Perform Romberg Test.

6. Perform Finger-to-Nose Test.

Procedure for Each Assessment

General Preparation

• Explain the Procedure: Ensure the client understands each step.

• Ensure Privacy and Comfort: Use draping and maintain a comfortable

room temperature.

• Gather All Necessary Equipment: Check functionality before starting.

Head and Face

 1. Inspect Head: Look for shape, size, and any abnormalities.

2. Palpate Scalp: Check for lesions, bumps, or tenderness.

3. Observe Face: Note symmetry, features, and any abnormal movements.

4. Facial Movements: Instruct the client to perform facial expressions to test

Cranial Nerve VII.

5. Test Sensations: Light touch or pinprick on forehead, cheeks, and chin for
Cranial Nerve V.

6. Palpate Temporal Arteries and TMJ: Check for tenderness and

movement.

Eyes

1. Visual Acuity: Use Snellen chart or similar.

2. External Inspection: Eyelids, lashes, sclera, and conjunctiva.

3. Pupillary Reactions: Direct and consensual response to light.

4. Accommodation: Near and distant focus.

5. Corneal Reflex: Light touch to cornea.

6. Ophthalmoscope Exam: Inspect retina and optic disc.

Ears

1. Inspect and Palpate External Ear: Check for deformities or tenderness.

2. Otoscope Exam: Inspect auditory canal and tympanic membrane.

3. Hearing Tests: Whisper test, Weber, and Rinne tests.

Nose and Sinuses

1. Inspect and Palpate Nose: Look for deformities, check for tenderness.

2. Airflow Patency: Occlude each nostril and assess breathing.

3. Smell Test: Use familiar scents to check olfactory function (Cranial Nerve I).

4. Otoscope Exam: Inspect internal nasal cavity.

5. Transillumination: Check for sinus fluid or congestion.

Mouth and Throat

1. Inspect Lips and Oral Cavity: Look for color, moisture, lesions.

2. Teeth and Gums: Note condition and alignment.

3. Palates and Uvula: Check movement and structure.

 4. Gag Reflex: Test for Cranial Nerve IX and X function.

5. Tongue: Inspect, palpate, and test strength (Cranial Nerves IX and X).

6. Taste Sensation: Use different tastes to test Cranial Nerves VII and IX.

Neck

1. Inspect and Palpate: Check for symmetry, lumps, and tenderness.

2. Range of Motion: Test flexion, extension, rotation.

3. Lymph Nodes: Palpate for enlargement or tenderness.

4. Thyroid Gland: Palpate and auscultate if necessary.

5. Carotid Arteries: Palpate and auscultate for bruits.

Arms, Hands, and Fingers

1. Inspect and Palpate: Check for color, swelling, and tenderness.

2. ROM Tests: Shoulders, elbows, wrists, fingers.

3. Pulses: Brachial, radial, and ulnar.

4. Reflexes: Biceps, triceps, brachioradialis.

5. Sensation Tests: Light touch, sharp/dull discrimination.

Posterior and Lateral Chest

1. Inspect: Look for deformities or use of accessory muscles.

2. Palpate: Check for tenderness or abnormalities.

3. Percuss: Identify resonance or dullness.

4. Auscultate: Listen for breath sounds, adventitious sounds.

5. Chest Expansion: Assess symmetry.

Anterior Chest

1. Inspect and Palpate: Check for symmetry, deformities.

2. Percuss and Auscultate: Assess for normal and abnormal sounds.

3. Skin Turgor: Test for hydration.

Breasts

1. Inspect and Palpate: Look for masses, dimpling, discharge.

2. Teach Self-Examination: Instruct on proper technique.

Heart
 1. Inspect and Palpate: Apical impulse, check for lifts or heaves.

2. Auscultate: Heart sounds, murmurs, at all key points.

Abdomen

1. Inspect: Look for contour, scars, distention.

2. Auscultate: Bowel sounds, vascular sounds.

3. Percuss and Palpate: Identify masses, tenderness.

Legs, Feet, and Toes

1. Inspect and Palpate: Look for swelling, varicosities.

2. ROM Tests: Hips, knees, ankles, toes.

3. Capillary Refill: Check perfusion.

4. Sensation Tests: Sharp/dull discrimination, vibration.

5. Special Tests: As needed based on findings.

Musculoskeletal and Neurologic Systems

1. Inspect Spine: Check for curvature, deformities.

2. Gait and Balance: Assess walking, tandem walk, Romberg test.

3. Coordination Tests: Finger-to-nose, heel-to-shin.

This guide ensures a thorough and systematic approach to collecting both

subjective and objective data during a nursing assessment, leading to accurate
clinical judgments and effective care planning.