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C349 - Health Assessment Video script
Comprehensive Health Assessment for Patients and Populations (C350)
Western Governors University
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Hi, my name is Joy Waldo and i will be completing a head to toe health assessment for C course
Introduce yourself to patient and ask for their name and ask why they are there Ask if there are any issues or if they are just there for a physical Medical history? Medications? Diagnosed with anything? Allergies to meds? Family hx? Social hx? Married? Children? Occupation? Smoke? Drink? Recreational drug use? Exercise? Immunizations? Flu shot? Pretend to take notes State height and weight Vital signs and go forward with head to toe BP - 120/ Temp - 97. Pulse and RR - 67 and 16
Assess skin and overall status of patient, check for lesions, wounds, sores, compare both sides, skin turgor, check hands, fingernails, capillary refill less than 3 seconds
Head and face - smile, surprise, frown, Assess head, hair distribution, dryness, lesions, open wounds, scalp, lumps or bumps, Move to frontal sinus and maxillary sinuses, any tenderness? Temporal artery, move to jaw and TMJ ask to open close mouth and clench, no clicking or popping? Pretend to take notes
Assess eyes, cover one eye, ASDFG, ASDFG have them sit again, penlight, check pupils, follow my finger, pupils are equal, round, reactive to late and they accomodate Do 6 cardinal fields of gaze, check conjunctiva, eyelashes, no drainage, pink and moist, any pain? No itching or watering?
Check nose with penlight, septum is intact, no drainage, ask to plug one nostril and other side? Move on to mouth, open mouth, hard and soft palate intact, pink gums, tongue out? Uvula rises appropriately? Have them push their tongue and put your hand on their cheek, ok midline symmetrical
Go into the ears, make sure there is no tenderness or pain or discharge, good elasticity, whisper test ask to plug one ear, roses are red violets are blue, symmetrical, whisper test on other side
Moving to the neck, check cervical nodes, make sure there is no swelling or pain, check thyroid, palpate and if it’s in the middle, carotid artery, auscultate pulse, no bruises noted
Check muscle strength and range of motion, do a shoulder shrug, head down, up, back, straight, left and right
Assess posterior, discoloration, petechiae, lumps or bumps, masses, do 99 on the back, take deep breath and check for symmetrical expansion, check for any tenderness on spinal cord, percuss and look for nice resonance sounds, costovertebral angle, listen to lungs with stethoscope
Move to the front, start listening to the heart, beginning with the aortic valve, now taking note of in this position the apical rate and rhythm and i did not hear any abnormalities, heard s1 and s
present, heart rate is regular, it is 65. Finish the rest of respiratory assessment in the front, look for any lumps or bumps and have pt say 99. Tell patient to breathe normally as i auscultate
Have patient do range of motions, squeeze hands, push hands up, push hands down, then have patient lie down to assess the abdomen, look at color and contour, any injuries or surgery done, equal distribution, color is nice, listen for bowel sounds so we dont disturb and making it hyperactive, start with right lower quadrant, reason why is because when were processing food, this is the first portal it enters from the small intestines, right upper quadrant, left lower quadrant, left upper quadrant. Next is to percuss when were percussing we can hear something that is solid, liver and spleen and things that are hollow. Ask patient if they can hear a difference Feel for liver borders, ask pt to take deep breath, light palpation to see for any distended areas then we’ll move to deeper palpation to see if there are any tenderness
Moving on to assessing femoral pulse, difficult to do on these pants but still able to feel for it, no prominent nodes felt in the area
Moving to the lower extremities, just doing a comparison with one side to the other, looking for symmetry and skin characteristics, see abrasions, scars, even hair distribution, feel for popliteal pulse, posterior tibealis pulse, dorsalis pedus pulse, and able to feel temperature, assess for edema, just press against the skin if there’s any indent, gives us indication if patient has fluid overload,
Move on to the toes, this is important if patient is diabetic, find any cracks or sores that they
might not even know is there, check temp and capillary refill, returns to pink in less than 3
seconds, no open areas or lesions, toes are cold but equally cold on both sides, next is assess
sensation, ask patient to let u know if they are being touched with something soft, sharp, with a
q tip and poke patient on their legs, do the same for the hands, do face as well, test for Babinski
reflex,
Have patient sit up and stand up, have patient face you and close their and tilt head back, have
them put their hands out, have one index finger touch the nose, do both sides, have patient
walk across, have patient come back and walk on their heels, walk on their tippy toes, have
patient put both hands on the side and walk with one foot in front of the other, test for
cerebellar function, take the heel of one foot and run it down the other shin, shallow knee
bend, lift leg and bend, check your notes if you missed anything
Have patient sit down and check reflexes, check bicep, if I had appropriate tools, I would be able
to do it, check radial reflex, do patellar reflex, Achilles reflex,
That is it. I did not find any abnormalities in the assessment but if we did find something, we
will address with your primary care provider and thank you for your time
C349 - Health Assessment Video script
Course: Comprehensive Health Assessment for Patients and Populations (C350)
University: Western Governors University
