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Comprehensive Health Assessment Checklist

Final Project Part I, the comprehensive health assessment, will be graded using the Final Project I Rubric. This checklist is a resource to help you plan for your client assessment, but you should not refer to it during the assessment. Refer to the Comprehensive Health Demonstration Video Guidelines document for recording guidelines.

Comprehensive Health Assessment Checklist

Complete this template by filling in the blank cells of each table.

Student Name	Date

Introduction	Done	Comments
1. Establish contract to perform assessment. (2 points)
2. Wash hands. (2 points)

Skin/Hair/Nails	Done	Comments
1. Inspect and palpate skin of arms and legs (note color, thickness, and any irregularities. (1 point)
2. Inspect and palpate nails of fingers and toes (note color, thickness, and any irregularities. (1 point)
3. Inspect the hair for distribution, texture (1 point)

HEENT

Head/Neck	Done	Comments
1. Inspect neck. (1 point)
2. Palpate and auscultate temporal arteries. (1 point)
3. Palpate frontal and maxillary sinuses. (1 point)
4. Palpate TMJ with patient opening and closing jaw. (1 point)
5. Palpate lymph nodes of head, clavicle, and axilla. (1 point)
6. Palpate thyroid from behind. (1 point)
7. Palpate and auscultate carotid arteries bilaterally one at a time. (1 point)

Eyes	Done	Comments
1. Inspect external eye. (1 point)
2. Palpate upper and lower eyelids. (1 point)
3. Test extraocular movements. (1 point)
4. Check pupillary reflex with penlight in both eyes. (1 point)
5. Test accommodation. (1 point)
6. Test peripheral vision. (2 points)
7. Test vision with Snellen chart or, if no chart is available, explain how you would do this. (1 point)

Ears	Done	Comments
1. Inspect external ears. (1 point)
2. Perform whisper test. (1 point)

Nose	Done	Comments
1. Inspect symmetry (1 point)
2. Assess for patent nares bilat (1 point)
3. Assess for sense of smell (1 point)
4. Inspect nares with penlight (1 point)

Throat	Done	Comments
1. Examine mouth: tongue, down, up, left, and right. (1 point)
2. Explain how you would test the gag. (1 point) Use tongue depressor touching each side of the pharynx
3. Inspect Oral Mucosa (1 point)

*Cardiac Have client seated, supine, and in the left lateral decubitus (LLD) position for this assessment**	Done	Comments
1. Inspect neck for JVD. (1 point)
2. Palpate pulses (bilaterally): PMI/heart patient on left side, brachial, carotid, radial, femoral, popliteal, posterior tibial, and dorsalis pedis. (5 points)
3. Auscultate with diaphragm to identify S1 and S2 at the sites listed below. (5 points) · Erbs point: 3rd LICS · Aortic: 2nd RICS · Pulmonic: 2nd LICS · Tricuspid: 4th LICS · Mitral: 5th LICS, midclavicular line Repeat with bell of stethoscope to assess for abnormal heart sounds.
4. Auscultate bilateral renal arteries, bilateral femoral arteries, and aorta. (2 points)
5. Palpate capillary refill in fingers and toes. (1 point)

Respiratory	Done	Comments
1. Palpate for fremitus. (1 point)
2. Palpate for symmetrical chest expansion. (1 point)
3. Check pulse oximetry or, if oximeter is not available, explain how to do this. (1 point)
4. Percuss anterior (6 locations) and posterior (10 locations) chest. (5 points)
5. Auscultate anterior (6 locations) and posterior (10 locations) chest with patient taking deep breaths and also when patient is saying, “99.” (5 points)

Gastrointestinal	Done	Comments
1. Inspect abdomen. (1 point)
2. Auscultate RLQ, RUQ, LUQ, LLQ. (1 point)
3. Percuss: three spots in each of the four quadrants in zigzag pattern, spleen, and liver span. (1 point)
4. Perform light palpation in all four quadrants. (3 points)
5. Explain how you perform deep palpation as well as how you would palpate liver, bilateral kidneys, and spleen. (2 points)
6. Perform abdominal exam in correct order. (1 point)
7. Percuss for CVA tenderness. (1 point)

Musculoskeletal	Done	Comments
1. Inspect joints: shoulders, elbows, wrists, fingers, spine, hips, knees, ankles, and toes. (1 point)
2. Neck: ROM forward, back, side to side, ear to shoulder, TEST STRENGTH forward, back, side to side. (1 point)
3. Shoulders: ROM flexion, extension, adduction TEST STRENGTH shoulder shrug. (1 point)
4. Arms: TEST STRENGTH flexion, extension. (1 point)
5. Elbows: ROM flexion, extension, pronation, supination. (1 point)
6. Hands/wrists: ROM flexion, extension, adduction, abduction TEST STRENGTH wrists up, wrists down, hand grasps. (1 point)
7. Spine: ROM flexion, extension, lateral bend, and rotation. (1 point)
8. Hips ROM flexion, extension, adduction, abduction TEST STRENGTH flexion. (1 point)
9. Knees: ROM flexion, extension TEST STRENGTH extension. (1 point)
10. Ankles: ROM dorsiflexion, plantar flexion, inversion, eversion, straighten and curl toes TEST STRENGTH dorsiflexion, plantar flexion. (1 point)

Neurological (May be integrated in Head-to-Toe)	Done	Comments
1. Assess Deep tendon reflexes bilaterally: biceps, patella, and Achilles. (2 points)
2. CN V: clench teeth, move jaw side to side, sharp and dull sensation face, corneal light reflex. (1 point) Note: CNs II, III, IV, VI, VIII, XI already tested during above assessment techniques.
3. CN VII: raise both eyebrows, frown, close eyes tight, smile. (1 point)
4. CNs IX, X, XII: open mouth, say “ahh,” stick out tongue. (1 point)

*Motor*	Done	Comments
5. Run heel down shin. (1 point)
6. Finger to nose. (1 point)
7. Walk across room. (1 point)
8. Walk heel to toe. (1 point)
9. Walk on toes. (1 point)
10. Walk on heels. (1 point)
11. Rapid alternating movements. (1 point)

*Sensory*	Done	Comments
12. Sharp/dull pain discrimination, arms and legs. (1 point)
13. Romberg test. (1 point)
14. Graphesthesia. (1 point)
15. Stereognosis. (1 point)

Psychiatric	Done	Comments
1. Orientation: person, place, time. (1 point)
2. Attention: counting backwards from 100 by 7s for one minute. (1 point)
3. Comprehension: give the patient a piece of paper with the following written on it: “Take paper in left hand, fold it in half, and place it on floor.” (1 point)
4. Long-term memory: ask patient how he or she celebrated his or her last birthday. (1 point)
5. Short-term memory: give patient four words and ask him or her to count backwards by 20 and then repeat the four words. (1 point)
6. Thank the patient. (1 point)