Complete Health Assessment NURS317L BINGE/HARRISON/MAIZE

Sequence: The Health History (5 points) Please submit the complete Chapter 23 Health History on your Health Lab Partner including cultural and spiritual assessments Data are subjective, documented in the clients own words

Appearance and Mental Status(5 points) Compare stated age with appearance Assess Level of Consciousness, Facial Expression, posture, position, hygiene, grooming Note Body odor, breath odor, skin color, SIGNS of pain? Ask the client his/her need to empty the bladder this will be an opportunity for urine collection. Proceed to wash hands explaining to the patient the procedure to be done (Complete Health Assessment) Measurements (10 points) Measure Height, weight, BMI calculation, Do Snellen Eye Chart Measure Vital Sign, radial pulse, respirations, temp, BP, Pain Skin, Hair& Nails: (5 points) Inspect the skin on the face, neck, and upper and lower extremities (other skin areas will be assessed as part of the system assessment) Inspect for color and uniformity of skin & hair color, describe and measure lesion, inspect scalp, hair for texture, distribution Palpate for skin temp, moisture, turgor, and edema Inspect fingernails for curvature, angle and color, Palpate the nails for cap refill and texture. Head, Neck and related Lymphatics (15 points) Inspect the neck for symmetry, pulsations, swelling, or masses Inspect skull for size, shape & symmetry, observe for facial expression(smile, grin , poof cheeks), Inspect features and movement (Cranial nerve V & VII) Palpate the skull and lymph nodes of the head and neck Palpate the muscle of the face (CN V) Assess range of motion and strength of muscles against resistance. Have patient move head Forward, backward, side to side, & shrug shoulders (CN XI) Palpate the trachea, palpate the thyroid for symmetry and masses Palpate and auscultate the carotid arteries one at a time

Eye(5 points) Inspect the external eye Inspect the pupils for color, size, shape and equality Test the visual fields (CN II) Test extraocular movements (CN III, IV, VI) Test pupillary response to light and accommodation (CN III) Darken the room to use the ophthalmoscope to assess the red reflex, optic disc, retinal vessels, Retinal background, macula and fovea centralis ( not required for this course) Ears, Nose, Mouth & Throat(10 points) Inspect the external ears, lips, nose for symmetry, lesions, discharge Assess patency of nares Test hearing using whisper, Weber and Rinne test (CN VIII) Test sense of smell ( not required fort this course ) Palpate the auricle and tragus of the ear Use otoscope to inspect the external ears, canals and tympanic membrane Use speculum to inspect the internal nose. Use penlight to inspect the tongue, palates, buccal mucosa, gums, teeth, tonsils, and oropharynx Observe the uvula for position and mobility as the client says ahh Test the gag reflex ( CN IX, X ) ** Note this is not required for this class ** Observe as the client protrudes the tongue (CN XII) Respiratory System, Breast, and Axilla(10 points) Start at the posterior chest Inspect the skin of the posterior chest for symmetry, musculoskeletal development, and thoracic Configuration, observe respiratory excursion Inspect and palpate the scapula & spine Palpate and percuss the costo-vertebral angle for tenderness Palpate for thoracic expansion and tactile fremitus (99) Percuss over lung fields, diaphragmatic excursion Auscultate breath sounds Inspect and assess the skin on anterior chest for symmetry and musculoskeletal development Assess for ROM and assess for movement against resistance of the upper extremities Breast Exam (not required - talk it out) Palpate the axillary, supraclavicular lymph nodes Palpate the anterior chest (lumps, bumps, lesions, tenderness) Percuss over lung fields Auscultate the anterior chest - include all obes Cardiovascular System(5 points) Inspect the neck for JVD or pulsations Inspect and palpate the chest for pulsations, heaves, lifts Palpate the apical pulse and note the intensity and location

Auscultate heart sounds, note the rhythm, rate, and location of S1 and S2 sounds The Abdomen (IAPP)(10 points) Inspect the Abdomen in all 4 quadrants, inspect the skin Inspect the abdomen for symmetry, contour, and movement or pulsation. Auscultate the abdomen for bowel sounds, vascular sounds (aortic stenosis) Percuss the abdomen in all Quadrants, percuss to determine liver, spleen, and kidneys Palpate the liver, spleen and kidneys, determine if tenderness, masses, or distention are present Palpate the inguinal region for pulses, lymph nodes, and presence of hernia (Not required for This course- talk it out) The musculoskeletal system(10 points) Test ROM and strength in hips, knees, ankles and feet Assist client to a standing position Inspect the skin of posterior and anterior legs Perform the Romberg test Observe the client s gait (walk back and forth) Observe the client walk heel to toe (Neuro assessment/coordination) Observe the client stand on right foot, then left foot with eyes closed (balance Vertigo) Observe the client do a shallow knee bend Stand behind the client and observe the spine as client touches the toes. Test Rom of the spine Neurological System(10 points) Light touch test, sharp test Sensory assess for pain, temperature Position test with clients eyes closed Test cerebellar function with finger-to-nose test, heel-shin test Test stereognosis, graphesthesia Test tendon reflexes (all extremities) Male /Female Reproductive (not required for This course) You may mention guidelines for when BSE and testicular exams are indicated as per recommendations.(You can look this up) / It is also in your textbooks!