What should be covered in a client's health assessment based on the system being studied.
Stated Age vs. Apparent Age: "Stated age congruent with apparent age."
Apparent State of Health: "Appears Healthy."
Signs of Distress: "No visible signs of distress."
Facial Expression: "Appropriate for situation."
Mood/Affect: "Appropriate for situation."
Speech: "Clear and coherent with appropriate pace and pitch."
Dress & Grooming: "Wearing clothing that is neat, clean, and appropriate to weather. Well-groomed."
Personal Hygiene (hair, skin, nails): "Appropriate personal hygiene- clean & no body odors noted."
Nutrition: "Appears well-nurished."
Body Symmetry: "Symmetrical body parts and no obvious deformity noted."
Stature: "Limbs and trunk appear proportional to body height."
Posture: "Sits and stands erect."
Motor Activity: "Coordinated movements."
Appearance & Behavior: "Appropriate to situation."
Cognitive Abilities & Judgment: "Able to answer questions and act appropriately to situation. Logical thought processes evident."
Memory: "Recent & Remote memory intact."
State of Awareness (Level of Consciousness): " Alert."
Orientation (Person, Place, Time): "Oriented X 3."
Face (CN V & VII)
Inspect Face for symmetry, movement, expression, sensation: "Bilateral symmetry of face with symmetrical facial movements, no involuntary movements, facial expressions appropriate to situation."
Inspect & palpate Hair for color, distribution, texture, etc.: "Hair is brown, fine, & evenly distributed."
Inspect & palpate Scalp for color, moisture, texture, mobility, and lesions: "Scalp color consistent with ethnicity, dry, smooth, moveable and without lesions."
Inspect & palpate Skull for general size, contour, and symmetry: "Normocephalic"
Neck (CN XI)
Inspect Neck for symmetry, Rand of Motion, & skin condition: "Neck symmetrical and without bulges. Skin intact and color consistent with ethnicity. Full ROM."
Inspect & palpate Trachea for position: "Trachea midline."
Palpate Lymph Nodes for size, mobility, consistency and tenderness (Preauricular, Postauricular, Occipital, Tonsillar, Submandibular, Submental, Superficial cervical, Deep cervical, Post cervical, Supraclavicular, Infraclavicular): "Lymph nodes non palpable except for postauricular nodes which are small, mobile, soft & nontender."
Palpate Carotid Pulses for quality and symmetry: "Carotid pulses +2 bilaterally."
Mouth (CN IX, X, XII)
Inspect lips for color, condition, and lesions: "Lips pink, moist & intact."
Inspect Oral Mucosa for color, conditions, lesions, and halitosis: "Oral mucosa pink, moist, & intact. No lesions. No halitosis."
Inspect Gums for color, condition, bleeding, and lesions: "Gums pink, moist, smooth and intact. No bleeding noted."
Inspect Teeth for color, condition, missing, or loose teeth: "Teeth white, straight and in good repair. Several fillings noted. Edges smooth. No caries noted."
Inspect Tongue for color, lesions, position & mobility (CN XII): "Tongue pink & moist without lesions. Midline position with full mobility."
Inspect Palates (hard & soft), Oropharnyx, Tonsils, & Uvula for color, condition, lesions, drainage and exudates. Assess CN IX & X via phonation (say "AHHH"): "Hard & soft palates, oropharnyx pink and intact. Tonsils present and without lesions or exudates. Uvula midline and rises with phonation. Positive swallow."
Inspect Paranasal Sinuses (frontal & maxillary) for swelling. Palpate for tenderness: "Frontal and maxillary sinuses non-tender to palpation. No swelling noted."
Inspect Nose for position, deformities, septal deviation, discharge, or flaring: "Nose midline and symmetrical. No deviation or flaring noted."
Assess for Patency of Nares: "Nares patent bilaterally."
Inspect Nasal Mucosa for color, intactness, & discharge: Nasal mucosa pink and moist. No discharge or lesions noted."
Palpate Nose for tenderness and deformities: "No tenderness or deformities of nose noted via palpation."
Inspect External Ears for position, color, size, shape, symmetry, lesions, drainage (clear, bloody, purulent) and visible cerumen: "Ears symmetrical and aligned with eyes. Normal size and shape. Color consistent with ethnicity. No redness, lesions, or drainage. Scant amounts of yellow cerumen visible in external canal of right ear."
Palpate External Ears for consistency and tenderness: " Helix soft, pliable and nontender. No nodules palpable."
Using an otoscope, inspect the Auditory Canal for skin color and patency: "Skin color of auditory canal consistent with ethnicity. Auditory canal patent bilaterally."
Inspect Tympanic Membrane for color, landmarks, & integrity: Tympanic membrane intact and pearly gray with landmarks visible bilaterally."
Assess Gross Hearing via the Whisper Test (auditory deficits)- test each ear separately: " Gross hearing intact bilaterally as able to repeat whispered word at 18" for each ear."
Eyes (CN II, II, IV, VI)
Inspect the Globe for position & alignment: Eyes symmetrical in alignment & position. No protrusion noted."
Inspect Eyebrows, Eyelids, and Eyelashes position, color, symmetry, lesions: "Eyelids symmetrical in alignment & position. Color consistent with complexion. No lesions or edema."
Inspect Lacrimal Apparatus: "Ducts patent bilaterally and without redness or discharge. No excessive tearing or dryness."
Inspect Conjunctiva for color, moisture, surface characteristics: "Conjunctiva in both eyes are pink and smooth without inflammation."
Inspect Sclera for color: "Sclera white & intact bilaterally."
Inspect Cornea and Lens for clarity & surface characteristics: "Corneas clear & without opacities, shiny and smooth in both eyes."
Inspect Iris for color, shape, clarity: Iris blue, clear & round in both eyes."
Inspect Pupils for size, shape, equality, reaction to light (direct & consensual), accommodation: "Pupils equal, round, reactive to light and accommodation/PERRLA."
Inspect Extraocular Eye Movements (CN III, IV, VI) for parallel alignment & symmetrical range of motion: "Eyes in parallel alignment with EOMs intact bilaterally. No nystagmus." (If assessment of corneal light reflex and/or EOMs reveal abnormalities, then the Cover/Uncover Test is performed)
Assess fields of Peripheral Vision by confrontation: "Peripheral vision intact in both eyes."
Assess Visual Acuity (CN II): "Snellen test 20/20 right eye. Snellen test 20/30 left eye.