TAGUM DOCTORS COLLEGE

Tagum City

PERFORMANCE CHECKLIST

PHYSICAL ASSESSMENT

Name: _________________________________ Grade: _________

Year: __________________________________ Date: _________

Assessing the Female Genitals and Inguinal Area

1. Assemble equipment and supplies:
*examination gloves
*Drape
*supplemental lightning
Assessment
2. Inspect the distribution, amount, and characteristics
of pubic hair.
3. Inspect the skin of the pubic area for parasites,
inflammation, swelling and lesions. To assess pubic
skin adequately, separate the labia majora and labia
minora.
4. Inspect the clitoris, urethral orifice, and vaginal orifice
when separating the labia majora.
5. Palpate the inguinal lymphnodes.
6. Document findings in the client’s record.
Assessing the Male Genitals and Inguinal Area
1. Assemble equipment and supplies:
• Examination gloves
Pubic Hair
2. Inspect the distribution, amount, and characteristics
of pubic hair.
Penis
3. Inspect the penile shaft and glans penis for lesions,
nodules, swellings and inflammation.
4. Inspect the urethral meatus for swelling,
inflammation, and discharge.
a. Compress or ask the client to compress the glans
slightly to open the urethral meatus to inspect it for
discharge.
b. If the client has reported a discharge, instruct the
client to strip the penis from the base to the urethra.
5. Palpate the penis for tenderness, thickening, and
nodules. Use your thumb and first two fingers.
Scrotum
6. Inspect the scrotum for appearance, general size,
and symmetry.
a. To facilitate inspection of the scrotum during a
physical examination, ask the client to hold the penis
out of the way.
b. Inspect all skin surfaces by spreading the rugaeted
surface of the skin and lifting the scrotum as needed
to observe posterior surfaces.
7. Palpate the scrotum to assess status of underlying
testes, epididymis, and spermatic cord. Palpate both
testes simultaneously for comparative purposes.
Inguinal Area
8. Inspect both inguinal areas for bulges while the client
is standing, if possible.
a. The client remains at rest.
b. Next, have the client hold his breath and strain or
bear down, as though having a bowel movement.
9. Palpate hernias.
10. Document findings in the client record.
Assessing the Rectum and Anus
1. Position the client.
In adults, a eft lateral or Sims position with the upper
leg accurately flexed is required for the examination.
a. For Females: a dorsal recumbent position with hips
externally rotated and knees flexed or lithotomy
position may be used.
b. For males: A standing position while the client bends
over the examining table may also be used.
Assessment
2. Inspect the anus and surrounding tissue for color,
integrity, and skin lesions.
a. Then ask the client to bear down as though
defecating.
b. Describe the location of all abnormal findings in terms
 of a clock, with the 12 o’clock position toward the
pubis symphysis.
3. Palpate the rectum for anal sphincter tonicity,
nodules, masses, and tenderness.
4. On withdrawing the finger from the rectum and anus,
observe it for feces.
5. Document findings in the client record.
Total: 150

Student’s signature over Printed Name Date signed: _____________

_______________________________
Clinical Instructor’s Signature Date signed: ____________
 TAGUM DOCTORS COLLEGE, INC.
TAGUM CITY

PERFORMANCE ASSESSMENT

Name:_____________________________ Grade___________
Year & section:______________________ Date____________

PHYSICAL ASSESSMENT 3

RATING
5 4 3 2 1
Assessing the Musculoskeletal System
1. Inspect the muscle for size. Measure the muscle with a tape.
2. Compare each muscle on one side of the body to the same muscle
on the other side for any apparent discrepancies.
3. Inspect the muscle and tendons for contractures and fasciculation.
4. Inspect any tremors of the hands and arms by having the client hold
the arms out in front of the body.
5. Palpate muscles at rest to determine muscle tonicity.
6. Palpate muscle while client is doing active range of motion. Check
flaccidity, spasticity, and smoothness of movement. Flexion and
extension movement)
7. Palpate muscle while the client is doing passive range of motion.
8. Test muscle strength. Compare the right side with left side.

a. Sternocleidomastoid: Client turns the head to one side against the

resistance of your hand. Repeat with the other side
b. Trapezius: Client shrugs the shoulders against the resistance of
your hands.
c. Deltoid: Client holds arm up and resists while you try to push it
down
d. Biceps: Client fully extends each arm and tries to flex it while you
attempt to hold arm in extension.
e. Triceps: Client flexes each arm and then tries to extend it against
your attempt to keep arm in flexion.
f. Wrist and finger muscles: Client spreads the fingers and resists as
you attempt to push the fingers together
g. Grip strength: Client grasps your index and middle fingers while
you try to pull the fingers out.
h. Hip muscles: Client is supine, both legs extended; client raises one
leg at a time while you attempt to hold it down.
j. Hip abduction: Client is supine, both legs extended. Place your
hands on the lateral surface of each knee; client spreads the legs
apart against your resistance.
k. Hip adduction: Client is in same position as for hip abduction. Place
your hands between the knees; client brings the legs together
against your resistance. Hamstrings: Client is supine, both knees
bent. Client resists while you attempt to straighten the legs.
l. Quadriceps: Client is supine, knee partially extended; client resists
while you attempt to flex the knee.
m. Muscles of the ankles and feet: Client resists while you attempt to
dorsiflex the foot and again resists while you attempt to flex the
foot.
Bones
1. Inspect the skeleton for normal structure and deformities.
2. Palpate the bone to locate any areas of edema or tenderness.
Joints
1. Inspect the joint for swelling.
2. Palpate each joint for tenderness, swelling, crepitation, and
presence of nodules.
3. Assess joint for ranger of motion, smoothness of movement.
4. Document pertinent findings in the client’s record.
Total: 130

Student’s signature over Printed Name Date signed: _____________

_______________________________
Clinical Instructor’s Signature Date signed: ____________
 TAGUM DOCTORS COLLEGE, INC.
TAGUM CITY

PERFORMANCE ASSESSMENT

Name:_____________________________ Grade___________
Year & section:______________________ Date____________

PHYSICAL ASSESSMENT 3

Neurologic Assessment
1. Determine the client orientation to time, place and person by tactful
questioning.
2. Determine client’s Level of Consciousness (RLS/GCS). Make use of
the Neuro Assessment Graphic Sheet.
3. Assess the Cranial Nerves
a. Cranial Nerve I- Olfactory
Ask the client to close eyes and identify different mild aromas, such
as coffee, alcohol, vanilla, alcohol.
b. Cranial Nerve II-Optic
Ask client to read Snellen’s chart and check visual fields by
confrontation.

c. Cranial Nerve III- Oculomotor

Assess six ocular movements ad pupil reaction.
d. Cranial Nerve IV- Trochlear, 6-Abducens
Assess six ocular movements. CN 6 assess ability to gaze laterally.
e. Cranial Nerve V- Trigeminal
While the client looks upward, lightly touch lateral sclera of eye to
elicit BLINK reflex. To test light sensation, have client close eyes,
and wipe a wisp of cotton over the client’s forehead and paranasal
sinuses. Use blunt and sharp ends of safety pin for deep sensation
over the same area.
f. Cranial Nerve VII-Facial
Ask client to smile, raise the eyebrows, frown, puff out his cheeks,
close his eyes tightly (against attempt to open them).
g. Cranial Nerve VIII- Acoustic (Vestibulocochlear)
Assess client’s ability to hear spoken words, and vibrations from
tuning fork (Apply Weber and Rinne Test)

h. Cranial Nerve IX- Glossopharyngeal

Depress the tongue with a tongue blade, and note pharyngeal
movement as the person says “ahhh” or yawns. Touch the posterior
pharyngeal wall with tongue blade and note the gag reflex. Apply
tastes on posterior tongue for identification.
i. Cranial Nerve X- Vagus
Assess with CN IX; assess client’s speech for hoarseness.
j. Cranial Nerve-XI-Spinal Accessory
Ask the client to shrug shoulder against resistance from your hands
and turn his head to side against resistance from your hand. Repeat
for the other side.
k. Cranial Nerve X- Hypoglossal
Ask client to protrude his tongue at midline, then move it’s side to
side.
Reflex
1 Biceps Reflex- test the spinal cord level C5-C6
Partially flex the client’s arm at the elbow, and rest the forearm over
the thighs, placing the palm of the hand down. Pace the thumb of
your nondominant hand horizontally over the biceps tendon.
Deliver a blow (slight downward thrust) with the percussion hammer
to your thumb. Observe the normal slight flexion of the elbow, and
feel the bicep’s contraction through your thumb.
2. Triceps Reflex- test the spinal cord level C7, C8
Flex the client’s arm at the elbow level, and support it in the palm of
your nondominant hand. Palpate the triceps tendon about 2-5 cm (1-
2in) above the elbow.
a. Deliver blow with the percussion hammer directly to the tendon.
Observe for the normal slight extension of the elbow
3. Brachioradialis Reflex- tests the spinal cord level C3, C6
Rest the client’s arm in a relaxed position on your forearm or on the
client’s own leg.
Deliver a blow with the percussion hammer directly on the radius 2-
5 cm (1-2in) above the bony prominence on the thumb side of the
wrist. Observe the normal flexion and supination of the forearm. The
fingers of the hand may also extend slightly.
4. Patellar Reflex- test the spinal cord level L2, L3, L4
Ask the client to sit on the edge of examining table so that his legs
hang freely.
Locate the patellar tendon directly below the patella.
a. Deliver a blow with the percussion hammer directly to the tendon.
Observe the normal extension or kicking out of legs as the
 quadriceps muscle contracts.
5. Achilles Reflex- tests the spinal cord level S1;S2.
With the client in the same position as for the patellar reflex, slightly
dorsiflex the client’s ankle by supporting the foot lightly in the hand.
a. Deliver a blow with the percussion hammer directly to the Achilles
tendon just above the heel. Observe and feel the normal plantar
flexion (downward jerk) of the foot.
6. Plantar(Babinski’s) Reflex-
Use moderately sharp object, such as the handle of percussion
hammer.
a. Stroke the lateral border of the sole of the client’s foot, starting at the
heel, continuing to the ball of the foot, and then proceeding cross the
ball of the foot toward the big toe. Observe for the response.
Normally, in adult all five toes bend downward.
Motor Function
Gross Motor and Balance Test
1. a. Walking Gait
Ask the client to walk across the room and back, and assess the
client’s gait.
b. Romberg’s test
Ask the client to stand with feet together and arms resting at the
sides, first with eyes open, then closed or 20-30 second without
support.
c. Standing with one foot with eyes closed
Ask the client to close his eyes and stand on one foot, then the other.
Stand close to the client during the test.
d. Heel-Toe Walking
Ask the client to walk a straight line, placing the heel of one foot
directly in front of the toes and then on the heels.
Fine motor Test for Upper Extremities
2. a. Finger to Nose Test
Ask the client to abduct and extend the arms at shoulder height and
rapidly touch the nose alternately with one index finger and then the
other. Have the client repeat the test with the eyes closed if the test
is performed easily.
b. Alternating Supination and pronation of hands and Knees
Ask the client to pat both knees with the palms of both hands and
then with the backs of the hands alternately at an ever-increasing
rate.
c. Finger to Nose and to the Nurse’s finger
Ask the client to touch the nose and then your index finger held at a
distance at about 4cm (18in) at a rapid and increasing rate.
d. Fingers to Fingers
Ask the client to spread the arms broadly at shoulder height and then
bring the fingers together at the midline, first with the eyes open and
then closed, first slowly and then rapidly.
e. Finger to thumb
Ask the client to touch each finger of one hand to the thumb of the
same hand as rapidly as possible.
Fine Motor test for the lower extremities
Ask the client to lie supine and to perform these test:
3. a. Heel Down opposite Shin
Ask the client to place the heel of one foot just below the opposite
knee and run the heel down the shin to the foot. Repeat with the
other foot. The client may also use a sitting position for this test.
b. Toe or Ball of Foot to the Nurse’s finger
Ask the client to touch your finger with the larger toe of each foot.
Light-touch Sensation
4. a. Compare the light touch sensation of symmetric areas of the body.
b. Ask the client to close the eyes and to respond by saying “yes” or
“now” whenever the client feels the cotton wisp touches his skin.
c. With a wisp of cotton, lightly touch specific spot and then the same
spot on the other side of the body.
d. Test areas on the forehead, cheek, hand, lower arm, abdomen,
foot, and lower leg. Check a specific area of the limb first.
e. Ask the client to point to the pot where the touch was felt.
f. If areas of sensory dysfunction are found, determine the
boundaries of sensation by testing responses about every 2.5cm
(1in) in the area. Make a sketch of the sensory loss area for
recording purposes.
5. Pain Sensation
Equipment: Broken tongue depressor
a. a. Assess pain sensation as follows:
b. Ask the client to close his eyes and to say “sharp”, “dull”, “don’t
know” when the sharp or dull end of the broken tongue depressor is
felt/
b. Alternately, use the sharp and dull end of the sterile pin or needle to
lightly prick designated anatomic areas at random. The face is not
tested in this manner. Allow at least 2 seconds between each test.
Temperature Sensation
6. Touch skin areas with test tubes filled with hot or cold water.
Have the client respond saying “hot”, “cold” or “don’t know”.
 Position or kinesthetic Sensation
7. Commonly, the middle fingers and the large toes are tested for the
kinesthetic sensation.
To test the fingers, support the client’s arm with one hand and hold
the client’s palm in the other. To test the toes, place the client’s heels
on the examining table.
Ask the client to close his eyes.
Grasp a middle finger or a big toes firmly between your thumb and
index finger and exert the same pressure on both sides of the finger
or toe while moving it.
a. Use a series of brisk up-and-down movement before bringing the
finger or toe suddenly to rest in one of the three positions.
Moving the finger of toe until it is up, down, or straight out, and ask
the client to identify the position.
Tactile Sensation
For the entire test, the client’s eyes need to be closed.
8. a. One-and-Two point Discrimination
Alternatively stimulate the skin with two pins simultaneously and
then one pin. Ask whether the client feels one or two pinpricks.
b. Stereognosis
Place familiar objects-such as key, paper clip, or coin-in the
client’s hand, and ask the client to identify them.

If the client has a motor impairment of the hand and is unable to

manipulate an object, write a number or letter on the client’s palm,
using a blunt instrument, and ask the client to identify it.
c. Extinction Phenomenon
Simultaneously stimulate two symmetric areas of the body, such
as the thighs, the cheeks, or the hands.
9. Document findings in the client’s chart.
Total: 245

Student’s signature over Printed Name Date signed: _____________

_______________________________
Clinical Instructor’s Signature Date signed: ____________