Health Assessment

John Knowles 20F

HEALTH HISTORY – Biographical data, reason for care, health history, family history, special considerations.
MENTAL STATUS – Appearance, behavior, LOC, cognition, though processes.
GENERAL SURVEY – Mobility, physical appearance, body structure.
VITALS
Height/Weight O2 Sat. TPR B/P Current Pain Target Pain
/ % / / / /10 /10

HEAD NECK
 Skin/Symmetry of facial features  Skin
 Hair/Scalp  Trachea
 CN 7 – motor/CN 5 – sensory  Mastoid Process
 Temporal pulses  Carotid Pulses
 Eyes – PERRLA/FOV  Carotid Bruits
 Ear  ROM
 Nose
 Oral/Dental

ANTERIOR THORAX POSTERIOR THORAX

 Skin  Skin
 Even chest expansion - visual  Even chest expansion - palpation
 Turgor  10 point breath sounds
 8 point breath sounds  Breath rate/rhythm/quality
 Breath rate/rhythm/quality
 Aortic/Pulmonic/Erbs/Tricuspid
 60 second Apical heart rate
 Heart rate/rhythm/quality

ARMS/HANDS ABDOMEN
 Skin  Skin
 Radial pulses  4 Quadrant bowel sounds
 Nails  4 Quadrant palpation
 Capillary refill  Questions: last bowel
 Strength/Resistance movement/diarrhea/constipation/
 ROM pain/tenderness

GENITOURINARY LEGS/FEET
 Skin  Skin/Edema
 Palpate bladder  Pedal pulses
 Questions: pain/urinary problems  Nails
 Capillary refill
 Strength/Resistance
 ROM