Health Assessment

 

Write up
Student Name:
Date: Total Points:

Assessment Area Point Allocation
Points &Instructor Comments
General Survey 5 Points

 

Integument

 

10 Points

Head, face & neck 10 Points

Eyes 10 Points

 

Ear, nose, & throat 10 Points

 

Respiratory

 

10 Points

Cardiac
10 Points
I
Abdomen 10 Points

Musculoskeletal 10 Points

 

 

Neurological 10 Points

 

 

 

Student Name: ______________________ Location: ______________________
Faculty:____________________________Final Grade:_____________________

 

Health Assessment Faculty Grading Rubric

 

 

System
Body part to be inspected Faculty:
Inspection
Check √ Grading Value Points
Earned
General Patient Survey Hand hygiene 10 Points
Patient identification
Patient Privacy
Assess vital signs
Assess orientation (person, place, time)
Assess level of consciousness
Observe posture and position
Note facial expression
Note hygiene, grooming, and dress
Note odors
Note mood and affect
Assess for pain
Assess for mobility equipment, dressings, etc

Integument Inspect head and scalp for color, hair distribution, and lesions 10 Points
Inspect for infestations
Inspect and palpate skin for texture, moisture, and temperature
Pinch skin fold over clavicle to check skin turgor
Note body-hair distribution on legs
Assess any wounds or lesions
Inspect for edema
Inspect nails of feet and hands
Check for clubbing
Check capillary refill

Head, face, and neck
Examine face for symmetry 10 Points
Test cranial nerve 5 by asking patient to bite down then close eyes and report light touch
Examine neck
Palpate carotid arteries
Check for thyroid enlargement
Check range of neck motion
Observe jugulovenous distention
Locate, name and palpate lymph nodes
Check cranial nerve 7 by having patient smile, frown, puff cheeks
Check cranial nerve 11 by having patient turn head to each side against resistance and shrug shoulders against resistance

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Eyes Note distribution of eyebrows and eyelashes 10 Points
Look for drooping of upper lids or sagging of lower lids
Note color of sclerae and defects or inflammation of bulbar conjunctivae
Inspect each iris
Note size and shape of pupils
Shine light onto each pupil and note response
Observe pupils for accommodation
Check alignment
Check extraocular movement and cranial nerves 3,4,&6 (six cardinal fields of gaze)
Identify red reflex
Check cranial nerve 2 (mention Snellen)

Ear, nose and throat Inspect ears for shape, placement, and discharge 10 Points
Check for tenderness by palpating pinna and tragus of each ear and by percussing over mastoid process
Test hearing and cranial nerve 8 (whisper test, finger rub, OR tuning fork)
Use otoscope to inspect ear canals and tympanic membrane
Check nose for alignment
Check the septum is midline
Note any discharge
Use penlight to check nasal mucosa
Check patency of nares (occlude opposite nostril)
Check cranial nerve 1 by asking to identify scent
Assess mouth, lips, oral mucosa, gums and teeth
Check tongue, throat, and tonsils
Test for rising uvula
Test ability to swallow
Check cranial nerve 12 (midline tongue protrusion, symmetry & position)
Check cranial nerve 9 & 10 (voice and gag)
Check articulation

Respiratory Compare inspiratory and expiratory phases of respiration 10 Points
Inspect thorax for symmetry and configuration
Note use of accessory muscles
Check posterior thorax for deformities
Palpate and percuss over anterior and posterior chest
Use diaphragm of stethoscope to auscultate over all lung fields (anterior & posterior)
Check lung expansion

Cardiac Palpate carotid arteries for rhythm and rate 10 Points
Use bell of stethoscope, listen to carotid arteries for bruits
Check for apical pulsation
Palpate point of maximal impulse
Auscultate over four cardiac landmarks

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Abdomen Observe abdomen contour from two angles 10 Points
Note symmetry, color, veins, lesions, scars, hair distribution, umbilicus, and abdominal movement
Auscultate bowel sounds in four quadrants
Using bell of stethoscope, auscultate abdominal aorta for bruits
Percuss four abdominal quadrants
Palpate four abdominal quadrants
Check for rebound tenderness
Check for costovertebral-angle (CVA) tenderness

Musculoskeletal Inspect overall appearance 10 Points
Observe gait, balance (tandem, tiptoe, heels), and motor function
Test upper-extremity coordination
Test lower-extremity coordination
Test muscle strength in upper and lower extremities
Perform Romberg test
Observe spine from lateral (looking for normal curvatures) and posterior views
Palpate along spine
Inspect and palpate skin and muscle groups of 2 joints (must be one upper & one lower)
Test range of motion and strength of the 2 joints selected
Check and name pulses (radial, pedal)

Neurological Test immediate, recent, and remote memory 5 Points
Make sure all 12 cranial nerves were assessed
Test deep tendon reflexes (one side on upper body and one side on lower body)

Total Assessment Performed in logical sequence, without too much patient position change, and within 20 min time limit

5 Points
Total % possible 100%