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Name: _________________________________ Date: _____________ Section/Group:________ Health Assessment CHECKLIST Legend: 3-Very Satisfactory 0- Did not perform the

procedure 2- Satisfactory 1- Needs Improvement PROCEDURES 3 2 1 Explain to the client what you are going to do, why it is necessary, and how he can cooperate. Wash hands and observe appropriate infection control procedures. Provide for client privacy. Determine the health history of the patient. Conduct the general survey. (physical presence, psychological presence and signs of distress) Get the anthropometric measurement (ht,wt,BMI,waist to hip ratio, skinfold thickness, midarm circumference) Get the vital signs. Conduct the head to toe assessment. Head: Inspect the evenness of growth over the scalp. Inspect hair thickness or thinness. Inspect hair texture and oiliness. Note presence of infections or infestations by parting the hair in several areas and checking behind the ears and along the hairline at the neck. Inspect amount of body hair. Palpate the head for the presence of lesions. Inspect the facial features. Note symmetry of facial movements. Let the patient frown, smile, clench his jaw and puff cheeks. Determine the sensory function of the facial nerve by the stroking cotton balls into the different areas of the face and do the sharp/dull or sharp/soft test. If necessary, perform the hot/cold test. Palpate the temporal artery and note the rate, rhythm, volume and symmetry. Auscultate to determine any bruit. Eyes Inspect the eyebrows for hair distribution and alignment and for skin quality and movement. Inspect the eyelashes for evenness of distribution and direction of curl. Assess the visual acuity by determining the distance and near vision. Inspect the bulbar conjunctiva for color, texture and the presence of lesions then Inspect the palpebral conjunctiva by everting the lids. Inspect and palpate the lacrimal gland. Inspect the cornea for clarity and texture. Ask the client to look straight ahead. Hold a penlight at an oblique angle to the eye, and move the light slowly across the corneal surface. Perform the corneal sensitivity (reflex) test to determine the function of the fifth (trigeminal) cranial nerve. Ask the client to keep both eyes open and look straight ahead. Approach from behind and beside the client, and lightly touch the cornea with a cotton ball. Inspect the pupils for color, shape, and symmetry of size. Assess each pupils direct and consensual reaction to light and accommodation. Assess peripheral visual fields. Assess six ocular movements to determine eye alignment and coordination. Ears Inspect the auricles for color, symmetry of size, and position. Palpate the auricles for texture, elasticity, and areas of tenderness. Perform the voice whisper test. Perform Weber test Conduct Rinne test Nose Inspect the external nose for any deviations in shape, size, or color and flaring, or discharge from the nares. Lightly palpate the external nose to determine any areas of tenderness, masses and displacements of bone and cartilage. Determine patency of both nasal cavities.Ask the patient to smell different kinds of scents.

Inspect the nasal cavities using a flashlight or a nasal speculum. Observe for the presence of redness, swelling, growths, and discharge. Inspect the nasal septum between the nasal chambers. Palpate and percuss the sinuses. Mouth Don gloves. Inspect the outer lips for symmetry of contour, color, and texture. Inspect and palpate the inner lips and buccal mucosa for color, moisture, texture, and the presence of lesions. Inspect the teeth and gums while examining the inner lips and buccal mucosa. Inspect the surface of the tongue for position, color, and texture. Ask the client to protrude the tongue. Inspect tongue movement. Ask the client to roll the tongue upward and move it from side to side. Ask the client to place the tip of his tongue against the roof of the mouth. Inspect the base of the tongue, the mouth floor, and the frenulum. Use a piece of gauze to grasp the tip of the tongue and, with the index finger of your other hand, palpate the back of the tongue, its borders and its base. Palpate the tongue and floor of the mouth for any nodules, lumps, or excoriated areas. Inspect the hard and soft palate for color, shape, texture and the presence of bony prominences. Ask the client to open his mouth wide ad tilt his head backward. Then, depress tongue with a tongue blade as necessary, and use a penlight for appropriate visualization. Inspect the uvula for position and mobility while examining the palates. To observe the uvula, ask the client to say ah so that the soft palate rises. Inspect the oropharynx for color and texture.Inspect one side at a time to avoid eliciting the gag reflex. To expose one side of the oropharynx, press a tongue blade against the tongue on the same side about halfway back and opens the mouth wide. Use a penlight for illumination, if needed. Inspect the tonsils for color, discharge and size. Elicit the gag reflex by pressing the posterior tongue with a tongue depressor. Let the patient taste different flavors. Remove gloves and wash hands. Neck Inspect the neck muscles (sternocleidomastoid and trapezius) for abnormal swellings or masses. Ask the client to hold her head erect. Observe head movement. Ask client to: Move her chin to the chest (determines function of the sternocleidomastoid muscle) Move her head back so that the chin points upward (determines function of the trapezius muscle) Move her head so that the ear is moved toward the shoulder on each side (determines function of the sternocleidomastoid muscle) Turn her head to the right and to the left (determines function of the sternocleidomastoid muscle) Assess muscle strength. Ask the client to: Turn her head to one side against the resistance of your hand. Repeat with the other side. Shrug her shoulders against the resistance of your hands. Palpate the entire neck for enlarged lymph nodes. Inspect, palpate and ascultate the carotid pulse. Inspect and determine for the presence of jugular vein distention. Palpate the trachea for lateral deviation. Place your fingertip or thumb on the trachea in the suprasternal notch, and then move your finger laterally to the left and the right in spaces bordered by the clavicle, the anterior aspect of the sternocleidomastoid muscle and the trachea. Inspect the thyroid gland. Stand in front of the client. Observe the lower half of the neck overlying the thyroid gland for symmetry and visible masses. Ask the client to hyperextend her head and swallow. If necessary, offer a glass of water to make it easier for the client to swallow. Palpate the thyroid gland for smoothness. Note any areas of enlargement, masses, or nodules. If enlargement of the gland is suspected: Auscultate over the thyroid area for a bruit. Thorax and lungs Posterior thorax Inspect the shape and symmetry of the thorax from posterior and lateral views. Inspect the spinal alignment for deformities. Have the client stand. From a lateral position, observe the three normal curvatures: cervical, thoracic, lumbar. To assess for lateral deviation of spine (scoliosis) observe the

standing client from the rear. Have the client bend forward at the waist and observe from behind. Palpate the posterior thorax. Palpate the posterior chest for respiratory excursion. Place the palms of both your hands over the lower thorax, with your thumbs adjacent to the spine and your fingers stretched laterally. Ask the client to take a deep breath while you observe the movement of your hands and any lag in movement. Palpate the chest for vocal (tactile) fremitus. Ask the client to repeat such words as blue moon or one, two, three or ninety nine. Percuss the thorax. Percuss for diaphragmatic excursion. Auscultate the chest using the flat-disc diaphragm of the stethoscope. Use the systematic zigzag procedure used in percussion. Ask the client to take slow, deep breaths through the mouth. Listen at each point to breath sounds during a complete inspiration and expiration. Compare findings at each point with the corresponding point on the opposite side of the chest. Anterior thorax Inspect breathing patterns. Palpate the anterior chest for respiratory excursion. Palpate for vocal (tactile fremitus) Percuss for diaphragmatic excursion. Auscultate the chest using the flat-disc diaphragm of the stethoscope. Heart Auscultate the heart rate at point of maximal impulse (PMI). Assess for the presence of murmurs, S3, S4 sounds. Auscultate others valves. Breast and Axilla Inspect breast size, contour, presence of retractions,etc. Do the breast exam accurately. Palpates foe lymph node enlargement especially at the tail of Spence. Abdomen Inspect the skin in the abdomen noting for lesions. Auscultates borborygmy sounds, and peritoneal friction rubs using the systematic assessment. Palpates for the liver and the bladder. Percuss all the areas of the abdomen using the systematic process. UPPER EXTREMITIES Does the musculoskeletal assessment. Assess for sensations to temperature, pain and touch. Palpates the radial pulse and reports the rate and quality. Assess for the nails and capillary refill. LOWER EXTREMITIES Does the musculoskeletal assessment. Assess for sensations to temperature, pain and touch. Palpates the different pulses and reports the rate and quality. Assess for the nails and capillary refill. For the next items, evaluate the students in general according to the criteria. (5 as the highest score) 5 4 3 2 1 Mastery Orderliness Proper attitude in assessing the client followed. Ability to answer questions Proper reporting observed. Evaluators Signature: __________________ Students signature: __________________ Comments:_____________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________