Full Heath Assessement Script Flash Cards

Question 1

What are the different sections of the health assessment?

Answer 1

Head
Upper Body
Lower Body

Question 2

What are the steps in the assessment of the head?

Answer 2

Introduction/handwash
Patient orientation
Health assist device questions
Penlight: eyes, nose, mouth
Head palpation
Observe Trachea placement
Lymph node palpation

Question 3

What is the response for patient orientation?

Answer 3

“Patient is alert and oriented times 4”
“There are no obvious abnormalities in appearance, speech, dress, and behavior”

Question 4

What is the response for eye observation?

Answer 4

“Pupils are 4 millimeters and PERRLA, no evidence of redness, drainage, or swelling of lids”

Question 5

What is the response for mouth observation?

Answer 5

“No discharge or redness in nasal cavity, good dentition, mucous membranes are moist, appropriate for race”

Question 6

What is the response for head and trachea observation?

Answer 6

“Head is normal cephalic” “Hair is evenly distributed, (HAIR COLOR) and fine.”

“Trachea is midline, and neck is symmetrical”

Question 7

What are the names and locations of the lymph nodes for palpation?

Answer 7

Question 8

What is the response for observation of the skin in the upper body portion of the health assessment?

Answer 8

“Color is appropriate for race, skin is smooth and dry, not oily. Skin is warm, intact, appropriate for race. No evidence of bruises or scars, some freckling. No other marks. Tattoos noted.”
“Major pressure points on upper extremities are intact, no evidence of breakdown”

Question 9

What is the response for nail inspection?”

Answer 9

“Nails are smooth, no ridges, clean, not discolored, no evidence of clubbing” DROP IT LOW.

Question 10

What is the response for cap refill?

Answer 10

“Cap refill is brisk, less than 2 seconds”

Question 11

What is the response for radial pulse observation?

Answer 11

“Radial pulses are 2 + bilateral”

Question 12

What is the response for finger grip strength?“

Answer 12

“Upper extremity strength 5/5 bilateral”

Question 13

What are the steps in the upper body portion of the health assessment?

Answer 13

Skin color/upper joint observation
Inspect nails/cap refill
Radial pulses/breath per min
Squeeze strength
Breathing assessment
Lung Sounds
APLA Ratio
Heart sounds
JVD/Carotid
Bowel Sounds

Question 14

What is the response for the breathing assessment?

Answer 14

“15 breaths per minute, No evidence of nasal flaring, retractions, labored breathing, or use of accessory muscles. There are no lifts or heaves.”

Question 15

What is the response to lung sounds?

Answer 15

“All lung fields are clear, no presence of cough, congestion, of adventitious lung sounds”

Question 16

After listening to the heart sounds, and palpating the PMI at the left midclavicular line, what is the response?

Answer 16

“Rate is 80 bpm, normal rhythm, S1 S2 noted, no murmurs, gallops, or rubs were heard”

Question 17

What is the response to the JVD and carotid observations?

Answer 17

“2+ bilateral” “No evidence of bruits or JVD”

Question 18

What are the steps in the abdominal assessment?

Answer 18

Observe stomach
Ask for pain
Listen for bowel sounds
Listen for clicks
Palpate belly

Question 19

What is the response to the observation of the abdomen?

Answer 19

“Abdomen is flat and symmetrical. No abnormal pulsations, peristalsis, or bulges.”

Question 20

What is the response after listening to bowel sounds?

Answer 20

“I’m going to count your clicks for one minute…I heard 15 clicks. Normal active bowel sounds in all quadrants.”

“Do you have any pain in your abdomen?”

Question 21

What is the response after palpation of abdomen?

Answer 21

“Did you feel any pain?”

Question 22

What are the steps in the lower body assessment?

Answer 22

Inspect knees, heels and legs
Feel legs, up and down
Check dorsalis pedis and tibialis pedis pulses
Toe Cap refill
Foot strength

LEAVE!

Question 23

What is the response to the knees, heels and leg observation?

Answer 23

“No gross abnormalities or joint deformities”

Question 24

What is the response to the feeling of the legs up and down?

Answer 24

“Skin is normal for race, warm, dry, and intact. No signs of pallor, rubor, or cyanosis. No rashes, lesions or ulcers. There is no edema.”

Question 25

What is the response to the dorsalis pedis and tibialis pedis?

Answer 25

“Dorsalis pedis is 2+, posterior tibialis is 2+”

Question 26

What is the response to the foot strength observation?

Answer 26

“Push against my hands, pull up”
“Bilateral strength in the lower extremities is 5/5”

Question 27

What questions do you ask to see if the patient is alert and oriented x4?

Answer 27

“Can you tell me your name and date of birth?”
“Do you know where you are?”
“Do you know why you are here?”
“Do you know what time it is?”