NUR 3066C Clinical Reasoning: Health Assessment

Mid-term - Partial Head-to-Toe Assessment

Name of Student Doing Assessment: Phoebe Williamson Missing Items and/or
Comments
Name of Peer Evaluator: Grace Kuenzli

PROFESSIONALISM
o Submits video on time
o Appropriate dress (wear scrubs) -giggled one time:)
o Maintains professional behavior (no giggling)
o Maintains appropriate language
Follow “SHIP”
o S= Supplies (gathers supplies needed--stethoscope & penlight)
o H=Hand hygiene before assessment starts (hand sanitizer)
o I= Introduces self/identifies patient with 2 identifiers (name of
patient and date of birth)
o P= Provides privacy (verbalize curtain pulled for privacy)
GENERAL TECHNIQUE
o Completes assessment in 10 minutes or less
o Uses skin to skin contact with stethoscope (verbalize once before
using stethoscope that would auscultate on skin )
o Assessment is organized and systematic (can be done by either body
system or body location; more than 2 times of “forgetting and going
back” is considered unorganized)
o Patient is appropriately positioned during exam
GENERAL SURVEY
o Verbalizes assessment of vital signs (verbalize vital signs were
completed)
o (S) Assesses for pain
o (O) Assesses physical appearance & posture (verbalize as patient is
sitting up in bed)
o (S) Assesses mood & affect (assess how patient feeling)
o (O) Assesses speech (verbalize if speech is clear & appropriate)
HEENT
o (O) Assesses head for symmetry
o (O) Assesses hair for texture, distribution, quality (describe hair,
such as soft evenly distributed, etc.)
o (O) Assesses eyes for pupil size (inspect pupil size in mm before
light shines on eyes)
o (O) Assesses eyes for PERRLA (assess if pupils equal, round,
reactive, to light and accommodation; shine penlight on eyes & have
patient look at finger from far/near)
o (S) Assesses for vision difficulties (ask if uses glasses/contacts)
o (S) Assesses for hearing difficulties (ask if wears hearing aids)
o (O) Assesses ears for drainage & symmetry (shine penlight on
outside of ears)
o (O) Assesses nose for drainage & symmetry (shine penlight up
nares)
o (O) Assesses mouth with penlight (shine penlight in mouth, cheek
teeth, tonsils)
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NUR 3066C Clinical Reasoning: Health Assessment
Mid-term - Partial Head-to-Toe Assessment
o (S) Assesses for swallowing (have patient swallow & ask if any
difficulties in swallowing)

RESPIRATORY
o (S) Assesses for shortness of breath
o (O) Evaluates breathing effort & pattern (assess if breathing is even,
regular, unlabored (no need to count respirations)
o (O) Inspects symmetry (AP diameter less than transverse) inspect
diameter
o (O) Auscultates anterior, posterior, & lateral (both sides) lung
sounds bilaterally for RUL, RML, RLL, LUL, LLL
CARDIOVASCULAR
o (S) Assesses for chest pain -Missing: Assesses for edema
o (O) Palpates carotid pulses individually bilaterally
o (O) Auscultates for carotid bruit (listen on both sides of neck)
o (O) Auscultates heart sounds using both bell and diaphragm of
stethoscope (aortic, pulmonic, tricuspid, mitral)
o (O) Auscultates rhythm of apical heart
o (O) Checks capillary refill in upper & lower extremities bilaterally
o (O) Assesses for edema bilaterally (in lower extremities,
pretibial/ankle areas)
o (O) Palpates radial pulses bilaterally
o (O) Palpates dorsalis pedis pulses bilaterally
o
S = Subjective; O = Objective

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