Health Assessment 2

Health assessment 2 H2T Introduction 1) **KNOCK** Hello, my name is Isabella Silva and I will be your nurse for today. I am here to complete a quick head to toe assessment that will take about 20 minutes, is that okay with you? 2) **HAND HYGIENE** * *PRIVACY** 3) What is your full name and DOB? **CHECK WRISTBAND** 4) Any allergies? 5) Any pain on a level of 0 being no pain and 10 being unbearable pain? General Appearance 1) 2) 3) 4) 5) 6) Do you know where you are today? What day of the week it is? Why you are here today? Pt is alert and oriented x4 No signs of acute distress Facial expression is flat, smiling, serious... Mood/affect is calm and corporative Speech is clear and understandable Skin and Nails 1) 2) 3) 4) 5) 6) Skin color is even and appropriate to ethnicity Skin has no lesions, wounds, or incisions Skin temperature is warm to touch Nail bed is pink and flat Capillary refill is <2 seconds **PLEASE DO A HEART FOR ME LIKE THIS** No signs of clubbing Head, Face, and Neck 1) **SANITIZE, GLOVES ON, GLOVES OFF, SANITIZE** Head is normocephalic. No lesions. No infestations. 2) ….. Eyes 1) **PLEASE LOOK STRAIGHT FOR ME. I WILL SHINE A LIGHT IN EACH EYE. KEEP LOOKING STRAIGHT AND FOCUS ON MY PEN WHENEVER I BRING IT CLOSER TO YOU** PEERLA is intact. 2) Eyes have no discharge or redness 3) **PULL YOUR EYES DOWN** Conjunctiva is pink. Sclera is white. 4) ……. Ears 1) **SHINE LIGHT EACH EAR** No discharge in the external auditory meatus. 2) …… whispered voice test Nose 1) **LIFT YOUR CHIN FOR ME, SHINE LIGHT IN NOSTRILS** No deformity, inflammation, or drainage. 2) Nose is symmetric. 3) **COVER ONE NOSTRIL FOR ME AND BREATH IN AND OUT. THE OTHER NOSTRIL PLEASE** Pt has bilateral patency Mouth & Throat 1) 2) 3) 4) 5) Lips are pink and moist Tongue is pink and moist Gums are pink and moist …….. ……. Respiratory System 1) No accessory muscles being used 2) **NOW EVERY TIME I PLACE MY STETOSCOPE ON YOUR CHEST BREATH IN AND OUT FOR ME** Right Upper Lung, Left upper lung, Right middle lung, Left Lower lung, Right lower lung. 3) Lung sounds heard in all anterior lung fields. 4) Left upper lung, right upper lung, left lower lung, right lower lung 5) Lung sounds heard in all posterior lung fields Cardiovascular/peripheral vascular 1) **RAISE BED TO 45 DEGREES** **LAY BACK AND PLEASE LOOK AT THAT CURTAIN/WALL** **SHINE LIGHT ON NECK AND FEEL CAROTID A. ON BOTH SIDES** 2) No JVD present bilaterally. Carotid artery Is regular rhythm, 2+ force bilaterally. 3) **NOW JUST RELAX WHILE I LISTEN TO YOUR CARDIAC FIELDS WITH THE DIAPHRAGM** Aortic 2nd intercostal space right of sternum, Pulmonic 2nd intercostal space left of sternum, Erb’s point 3rd intercostal space left of sternum, Tricuspid 4th intercostal space left of sternum, Mitral 5th intercostal space left midclavicular line. S1 and S2 heard in all cardiac fields. 4) **NOW I WILL LISTEN WITH MY BELL** No murmurs noted on any of the cardiac fields. 5) **NOW I WILL PALPATE FOR YOUR RADIAL PULSES** Regular rhythm, 2+ force, bilaterally. 6) **NOW PLEASE REMOVE YOUR SHOES AND SOCKS FOR ME, I WILL ASSESS FOR EDEMA ON THE LEGS. PALPATE BOTH LEGS ALL THE WAY DOWN** **LET ME KNOW IF YOU FEEL ANY TENDERNESS OR PAIN WHENEVER I TOUCH** No edema present. 7) **I WILL NOT PALPATE YOUR DOSALIS PEDIS** (top of foot) equal 2+ force regular rhythm bilaterally. 8) **LASTLY ILL PALAPTE THE POSTERIOR TIBIALIS** (back side of ankle) equal 2+ force regular rhythm bilaterally. Gastrointestinal/Urinary 1) **LET ME BRING THE BED ALL THE WAY DOWN, LAY BACK FOR ME AND RELAX** Abdomen is flat and symmetric 2) **RELAX WHILE I AUSCULTATE YOUR ABDOMEN** Right lower quadrant, right upper quadrant, left upper quadrant, left lower quadrant. Bowel sounds heard in all 4 quadrants. 3) **NOW I WILL LIGHTLY PALPATE YOUR ABDOMEN. PLEASE LET ME KNOW IF YOU FEEL ANY TENDERNESS OR PAIN WHEREVER I TOUCH** RLQ, RUQ, LUQ, LLQ. No tenderness or distention. Musculoskeletal 1) ….. Closure 1) Well that concludes the end of my assessment. How is your pain level now on a scale of 0-10? 2) I will lower, lock, and raise the rails of your bed so you can feel comfortable and safe. 3) Here is the call light if you need anything 4) Thank you so much for letting me assess you today. 5) **HAND HYGIENE** EXIT.