Health Assessment Final Pass Off

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  1. Eyes
    • Abnormalities: Glaucoma/Strabismus (crossed Eye)
    • Test 
    • Acuity Confrontation: Peripheral Vision intact
    • Cardinal (6 points) bilateral eye movement CNS 3, 4, and 6 intact
    • Cover and uncover: steady fixed gaze bilaterally
    • Corneal Light Reflex: symmetrical light reflex
    • PERRLA: Pupils equal, round, reactive to light and accommodation
    • Red Reflex (Ophthalmoscope) Positive red reflex observed bilaterally

    • Inspect
    • Relaxed Facial Expression
    • External
    • Upper eyelids: approximate completely when closed
    • Orbits: symmetric bilaterally, no peripheral edema noted
    • Lacrimal Glands and Ducts: No swelling, redness or excessive tearing palpate in the inner eye next to nose
    • Eyelashes: evenly distributed bilaterally
    • Eyeballs: aligned bilaterally
    • Conjunctiva: clear, pink over lower lids, white over sclera bilaterally (look up and pull down lower lids)
    • Sclera: white
    • Internal
    • Cornea: smooth and clear Shine a light
    • Iris : round, regular shape with even coloration bilaterally
    • Pupil: size 2mm bilaterally
  2. Head and Face
    • Inspect skin characteristics
    • Inspect symmetry and external characteristics of eyes and ears
    • Inspect and palpate scalp and hair for texture, distribution and quantity
    • Palpate sinus region     
    • Palpate temporomandibular joint
    • Ask client to clench teeth, squeeze eyes tightly shut, wrinkle forehead, smile, stick out tongue puff out cheeks (CN VII)
    • Test light sensation of forehead, cheeks, chin (CN V)
  3. Ears
    Abnormalities: Acute Otitis Media (AOM)/Hearing Loss (DEAF)

    • Inspect external structures of the ear, alignment, configuration, and abnormalities:Ears equal size bilaterally with no swelling or thickening noted.  Skin intact.  Darwin's tubercle present bilaterally.  External auditory meatus without swelling, redness, or discharge bilaterally.
    • Inspect and describe each ear canal, note abnormalities: External canal without redness, swelling lesions, foreign bodies, or discharge.  Cerumen present bilaterally.
    • Inspect and describe tympanic membrane: Tympanic membrane shiny and translucent with a pearly-gray color bilaterally.  Light reflex prominent in the anterior inferior quadrant bilaterally.  Appears flat; slightly pulled at center.
    • Perform whisper test and describe findings (CN VIII): repeat at least 3 out of a possible 6 numbers/letters whispered bilaterally.
  4. Nose
    Abnormalities: sinusitis/fractured nose/seasonal allergies

    • Inspect skin characteristic, midline:Nares symmetric; nose midline and in proportion to other facial features.  No inflammation, deformity or skin lesions noted. 
    • Determine patency of each nostril: Nares patent bilaterally
    • Inspect mucosa, septum, turbinates:Nasal mucosa red, smooth, moist surface; no discharge or foreign body noted.  No septal deviation, perforation or bleeding noted.  Turbinates gray and gobby due to allergies with small polyp left are, and no growths noted.
    • Assess olfactory function, test sense of smell (CN I):CN I intact web patient's ability to identify appropriately an aroma bilaterally
  5. Mouth and Pharynx
    • Inspect condition of lips, gums, teeth
    • Inspect condition of buccal mucosa, tongue, hard and soft palates, floor of mouth, ducts
    • Inspect oropharynx, grade tonsils
    • Inspect tongue, symmetry, movement (CN XII)
    • Assess TMJ and range of motion of jaw
    • Note if uvula elevates in midline when patient
    • Says “ahh” and test gag reflex (CN IX, X)
  6. Neck
    • Inspect for symmetry of neck structures/muscles
    • Inspect for jugular vein distention
    • Inspect range of motion
    • Test shoulder shrug & head resistance against   Examiner’s hand (CN XI)
    • Palpate tracheal position
    • Palpate thyroid
    • Palpate lymph nodes:  
    • * pre  
    • * post auricular                    
    • * occipital                    
    • * jugulodigastic                    
    • * submandibular                    
    • * submental                    
    • * superficial,  
    • * deep  
    • * posterior, cervical chain                    
    • * supraclavicular
    • Auscultate carotid arteries: No Bruit noted
  7. Chest/Lung Examination
    • Inspect for symmetry, contour (AP/transverse ratio) note deformities
    • Assess breathing rate, pattern, depth, effort
    • Palpate for symmetry of chest expansion (posterior only)
    • Percuss posterior lung fields only, note predominant sound and symmetry
    • Auscultate anterior/posterior/lateral lung fields, note findings                    
    • In terms of breath sounds heard, presence or absence adventitious sounds
  8. Cardiovascular System: FETCO
    • Force (pulses: radial, posterior tibial, dorsalis pedis
    • Edema (no edema in the upper and lower extremities)
    • Temperature (warm equal bilaterally upper and lower extremities
    • COlor even and consistent with genetic background
  9. Abdomen
    • INSPECT: 
    • Contour: Flat, Rounded, Scaphoid (undernutrition), Distended
    • Aortic pulsation (light from side) *visible 1 cm above umbilicus
    • Symmetry
    • Smooth Skin
    • Abnormalities: no lesions, scars, striae (abnormalities)

    • AUSCULTATE
    • Normoactive Bowel Sounds present in all 4 quadrants

    • PERCUSS
    • Tympany predominates abdomen
    • Liver: measure span (6-12 cm)

    • PALPATION          
    • No swelling, enlargement, or tenderness
    • Unable to palpate: SPLENE, LIVER, KIDNEYS
    • CVA tenderness
  10. Neuromuscular
    • UPPER EXTREMITIES:
    • Strength
    • Grip
    • Resistance
    • Range of motion
    • Nose to Fingers (Close Eyes)

    • BOTH EXTREMITIES
    • LIGHT vs SHARP (Eyes close)
    • REFLEXES: Biceps, Triceps, Patellar, Achilles 
    • LOWER EXTREMITIES:
    • Plantar (Positive) vs Babinski (only for BABY – Negative)
    • Heel to Tibia
    • Spine:
    • Inspection: Bend over
    • Range of Motion:
    • Hyperextension
    • Lateral bend
    • Rotation

    • GAIT:
    • Romberg’s Test
    • Heel to Toe (Tandem walking)
    • Gait

Card Set Information

Author:
keahi702
ID:
325981
Filename:
Health Assessment Final Pass Off
Updated:
2016-11-23 07:10:11
Tags:
Final Pass Off
Folders:
Health Assessment
Description:
health assessment final pass off
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