Health Assessment Final Evaluation Checklist

Vocabulary flashcards covering key terms and assessment steps from the Health Assessment Final Evaluation checklist.

Hand Hygiene

Wash hands

Introduce self

Hi I’m Hayley, I’ll be your student nurse today completing a head to toe assessment

Check patient identification on wrist band

Confirming a patient’s name and date of birth while looking at bracelet

Provide Privacy

Close curtains

Assess the patient’s physical appearance

Patient looks stated age; is alert and oriented with no signs of acute distress

Assess the patient’s body structure

height and weight appear normal for age with erect posture

Assess the patient’s mobility

gait was smooth and coordinated when the patient walked in the room with no evidence of involuntary movements.

Assess the patient’s behavior

Patient made eye contact, facial expressions were appropriate, speech was clear, hygiene and grooming are appropriate for the weather

Assess for pain

pain scale 0-10

Assess Mental Status – Orientation, level of consciousness, memory. What is your name? Where are you? What time is it? What did you have for dinner last night?

Patient is alert, oriented to person, place, time, short term memory intact

Inspect skin for rashes, bleeding, bruising and lesions in upper extremities and lower extremities

Skin clear

Palpate skin for temperature, texture, and moisture using back of hands in upper extremities and lower extremities

Skin warm, dry and smooth

Assess Skin Turgor-pinch clavicle

no tenting at clavicle

Inspect nail condition of both hands

nails convex shape, cuticles pink

Palpate nails for texture

nails firm and smooth

Inspect hair and scalp

hair evenly distributed, no evidence of lesions or infestations

Inspect shape of the head and face for symmetry

head normocephalic, color appropriate for ethnicity, features symmetrical

Inspect External Eye Structures

Lids, lashes, brows, and eyeballs symmetrical, no edema

Examine pupils for equality, size, shape, reaction to light

Pupils Equal, Round, Reactive to Light

Inspect lips, oral mucosa, hard, soft palate, gums, teeth, tongue

lips, oral mucosa, hard and soft palate and gums are pink, moist, smooth; teeth intact

Inspect the trachea

trachea midline

Inspect Posterior Thorax

skin clear, positive symmetry of expansion, no use of accessory muscles

Palpate for symmetry of expansion on posterior thorax- place hands on back

positive symmetry of expansion

Auscultate the posterior thorax (6-8)/sequence

clear bilaterally in all lung fields

Auscultate lateral thorax(2)

clear bilaterally in all lung fields

Inspect Anterior Thorax

skin clear, positive symmetry of expansion, no use of accessory muscles

Auscultate The Anterior Thorax(4)

clear bilaterally in all lung fields

Inspect, palpate, and auscultate carotid arteries (USE BELL, ONE SIDE AT A TIME)

no bruit ascultate

Inspect for Jugular Vein Distention (JVD)

inspect both sides of neck, no evidence of jugular vein distention

Systematic auscultation, aortic, pulmonic, Erb’s, tricuspid, mitral

S1 S2 regular rate and rhythm

Palpate Radial and Brachial Pulses separtely and capillary refill time in fingers on both hands

equal pulses bilaterally and less than 3 seconds capillary refill time

palpate for bilateral posterior tibial and dorsal pedis pulses and capillary refill in toes on both feet

equal pulses bilaterally and less than 3 seconds capillary refill time

Posterior Tibial Pulse

Pulse behind the medial malleolus of the ankle; assessed bilaterally.

Inspect abdomen

non distended, umbilicus centrally located, symmetric, skin clear

Auscultate all four quadrants

Positive bowel signs in all 4 quadrants

Percuss

Now is where I would percuss, but that is not a part of this exam

Palpate the abdomen lightly in all 4 quadrants

soft, non-tender, no masses

Patient shrugs against resistance, cheek resistance

equal strength bilaterally

Neck Range of Motion (ROM) (6 positions)

range of motion smooth and controlled

flex upper arm and to resist examiner’s opposing force

equal strength bilaterally

Squeeze two fingers

equal strength bilaterally

raise thigh against resistance

equal strength bilaterally