Comprehensive Health Demonstration
Comprehensive Health Demonstration
omprehensive Health Assessment Checklist
Final Project Part I, the comprehensive health assessment, will be graded using the Final Project I Rubric. This checklist is a resource to help you plan for your client assessment, but you should not refer to it during the assessment. Refer to the Comprehensive Health Demonstration Video Guidelines document for recording guidelines.
Comprehensive Health Assessment Checklist
Complete this template by filling in the blank cells of each table.
Student Name
Date
Introduction
Done
Comments
1. Establish contract to perform assessment. (2 points)
2. Wash hands. (2 points)
Skin/Hair/Nails
Done
Comments
1. Inspect and palpate skin of arms and legs (note color, thickness, and any irregularities. (1 point)
2. Inspect and palpate nails of fingers and toes (note color, thickness, and any irregularities. (1 point)
3. Inspect the hair for distribution, texture (1 point)
HEENT
Head/Neck
Done
Comments
1. Inspect neck. (1 point)
2. Palpate and auscultate temporal arteries. (1 point)
3. Palpate frontal and maxillary sinuses. (1 point)
4. Palpate TMJ with patient opening and closing jaw. (1 point)
5. Palpate lymph nodes of head, clavicle, and axilla. (1 point)
6. Palpate thyroid from behind. (1 point)
7. Palpate and auscultate carotid arteries bilaterally one at a time. (1 point)
Eyes
Done
Comments
1. Inspect external eye. (1 point)
2. Palpate upper and lower eyelids. (1 point)
3. Test extraocular movements. (1 point)
4. Check pupillary reflex with penlight in both eyes. (1 point)
5. Test accommodation. (1 point)
6. Test peripheral vision. (2 points)
7. Test vision with Snellen chart or, if no chart is available, explain how you would do this. (1 point)
Ears
Done
Comments
1. Inspect external ears. (1 point)
2. Perform whisper test. (1 point)
Nose
Done
Comments
1. Inspect symmetry (1 point)
2. Assess for patent nares bilat (1 point)
3. Assess for sense of smell (1 point)
4. Inspect nares with penlight (1 point)
Throat
Done
Comments
1. Examine mouth: tongue, down, up, left, and right. (1 point)
2. Explain how you would test the gag. (1 point)
Use tongue depressor touching each side of the pharynx
3. Inspect Oral Mucosa (1 point)
Cardiac *Have client seated, supine, and in the left lateral decubitus (LLD) position for this assessment
Done
Comments
1. Inspect neck for JVD. (1 point)
2. Palpate pulses (bilaterally): PMI/heart patient on left side, brachial, carotid, radial, femoral, popliteal, posterior tibial, and dorsalis pedis. (5 points)
3. Auscultate with diaphragm to identify S1 and S2 at the sites listed below. (5 points)
· Erbs point: 3rd LICS
· Aortic: 2nd RICS
· Pulmonic: 2nd LICS
· Tricuspid: 4th LICS
· Mitral: 5th LICS, midclavicular line
Repeat with bell of stethoscope to assess for abnormal heart sounds.
4. Auscultate bilateral renal arteries, bilateral femoral arteries, and aorta. (2 points)
5. Palpate capillary refill in fingers and toes. (1 point)
Respiratory
Done
Comments
1. Palpate for fremitus. (1 point)
2. Palpate for symmetrical chest expansion. (1 point)
3. Check pulse oximetry or, if oximeter is not available, explain how to do this. (1 point)
4. Percuss anterior (6 locations) and posterior (10 locations) chest. (5 points)
5. Auscultate anterior (6 locations) and posterior (10 locations) chest with patient taking deep breaths and also when patient is saying, “99.” (5 points)
Gastrointestinal
Done
Comments
1. Inspect abdomen. (1 point)
2. Auscultate RLQ, RUQ, LUQ, LLQ. (1 point)
3. Percuss: three spots in each of the four quadrants in zigzag pattern, spleen, and liver span. (1 point)
4. Perform light palpation in all four quadrants. (3 points)
5. Explain how you perform deep palpation as well as how you would palpate liver, bilateral kidneys, and spleen. (2 points)
6. Perform abdominal exam in correct order. (1 point)
7. Percuss for CVA tenderness. (1 point)
Musculoskeletal
Done
Comments
1. Inspect joints: shoulders, elbows, wrists, fingers, spine, hips, knees, ankles, and toes. (1 point)
2. Neck: ROM forward, back, side to side, ear to shoulder, TEST STRENGTH forward, back, side to side. (1 point)
3. Shoulders: ROM flexion, extension, adduction TEST STRENGTH shoulder shrug. (1 point)
4. Arms: TEST STRENGTH flexion, extension. (1 point)
5. Elbows: ROM flexion, extension, pronation, supination. (1 point)
6. Hands/wrists: ROM flexion, extension, adduction, abduction TEST STRENGTH wrists up, wrists down, hand grasps. (1 point)
7. Spine: ROM flexion, extension, lateral bend, and rotation. (1 point)
8. Hips ROM flexion, extension, adduction, abduction TEST STRENGTH flexion. (1 point)
9. Knees: ROM flexion, extension TEST STRENGTH extension. (1 point)
10. Ankles: ROM dorsiflexion, plantar flexion, inversion, eversion, straighten and curl toes TEST STRENGTH dorsiflexion, plantar flexion. (1 point)
Neurological (May be integrated in Head-to-Toe)
Done
Comments
1. Assess Deep tendon reflexes bilaterally: biceps, patella, and Achilles. (2 points)
2. CN V: clench teeth, move jaw side to side, sharp and dull sensation face, corneal light reflex. (1 point)
Note: CNs II, III, IV, VI, VIII, XI already tested during above assessment techniques.
3. CN VII: raise both eyebrows, frown, close eyes tight, smile. (1 point)
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