253 Script Health Assessment PDF

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final assessment notes ...

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253 Script FIRST: MAKE SURE YOU BRING RUBRIC WITH YOU TO TESTOUT Introduce yourself to the patient “hello, my name is _______ I will be your nurse today” • Can I please have your name and DOB (2 identifiers) • Perform hand hygiene NEUROLOGICAL 1. Start by assessing LOC x4 (can you tell me) • Who I am? (person) • Where you are? (place) • What time/day it is? (time) • Why you are here? (situation) Stated finding: Patient is alert and oriented X4 to person, place, time and situation. 2. Take out penlight, look at pupil size State finding: Pupils are 3mm (usual size) Cranial nerve 3 Next: assess PERRLA, shine the light briefly laterally on each eyeball, look for opposite pupil constriction, pupillary constriction should be equal bilaterally. Finally test accommodation by holding penlight 12 inches in front of the patient and make a swinging arm motion up to 4 inches in front of their nose. Both eyes should converge towards the nose to show Accommodation. State finding: Pupils are equal, round, and reactive, to light and accommodation 3. Assess facial symmetry and if tongue is midline (have patient stick out tongue) after, have patient smile State findings: face is symmetrical bilaterally, eyes are symmetrical and in line with the ear, nose is midline, smile/lips are even and symmetrical tongue is midline 4. Cranial Nerves • 1: Olfactory (S) (have them close eyes, use a sanitizer wetted cotton ball and have them sniff it) • 2: Optic (S) (Snellen chart), visual fields intact by confrontation • 3: Ocular motor (M) (EOM intact by 6 cardinal fields of vision) • 4: Trochlear (M) (cardinal fields of vision) • 5: Trigeminal (S/M) (sensory: have them close eyes, use a cotton ball and lightly touch sides of face, patient should verbalize that they feel it, motor: pull down on jaw and have them close it against resistance) • 6: Abducens (M) (cardinal fields of vision) • 7: Facial (B) (sensory: sensory: have them close eyes, use a cotton ball and lightly touch sides of face, motor: have them smile, look for facial symmetry) • 8: Auditory (S) (whisper test)

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9: Glossopharyngeal (B) (have them swallow/gag) (both 9&10 have same tests) 10: Vagus nerve (B) (don’t need to test) but gag reflex/swallow 11: Accessory (M) (“#11 shoulders go to heaven”) shrug your shoulders against resistance, press down using hands bilaterally and have patients lift shoulders) 12: Hypoglossal (M) (stick out tongue because you’re done!) and move tongue side to side

Skin: during test out wounds might be present, look at wound, palpate around for warmth, ask if any pain during palpation, assess color/size/drainage present for thoracic, abdomen, and assessment in upper and lower extremities THORACIC 5. 1 subjective question pertaining to Thorax, Lungs (Have you had any breathing difficulties recently?) 6. Observe quality and pattern of respirations State findings: quality of breaths are regular, deep and pattern rhythmic and equal bilaterally, no signs of respiratory distress such as: Nasal flaring, sternal retractions, or pursed lips present upon observation. 7. Auscultate breath sounds and state findings (instruct patient to remove shirt/ top) • 8 spots anteriorly, 10 posteriorly, move in a “snake pattern” starting below the right clavicle • Instruct the patient to take a deep breath with each change in stethoscope location • Make sure you have the diaphragm equipped • The anterior lateral lobe , 4 each, should be auscultated when starting anteriorly State Findings: Clear breath sounds heard in all 5 lobes; no adventitious breaths sounds heard upon auscultation. Patient is on room air, no cough (if cough: state productive/ nonproductive and color of secretions) 8. Palpate for chest expansion and tenderness • Chest expansion: place hands on each side of thoracic cage, should instruct patient to breath inward, should note sizable chest expansion (more than 3 inches) State Finding: chest expansion is at least 3 inches and is equal bilaterally • Tenderness: using palm, palpate starting posteriorly at least 10 spots alternating left and right side down patients back State finding: no tenderness or discomfort reported upon palpation CARDIAC 9. Ask 1 subjective Cardiac question (have you had any chest pain recently?)

10.Assess for carotid pulse: (DON’T DO BILATERALLY) State findings: patient has a palpable carotid pulse and is present +2, rate is ______ pulse is not bounding or thready, rhythm is regular 11.Palpate apical pulse (instruct patient to remove shirt/top) State findings: Apical pulse is present upon palpation along the midclavicular line at the 5th intercostal space (rate is _____ and rhythm is regular 12.Auscultate Apical Rate and rhythm State findings: Apical rate is _____ and rhythm is regular 13.Auscultate Heart sounds (using both diaphragm, and bell) STATE THAT YOU ARE USING THE DIAPHRAGM AND THAT YOU ARE LISTENING TO EACH SPOT AS YOU MOVE THE STETHOSCOPE Auscultate with diaphragm • “ I am auscultating the:” Aortic: 2nd intercostal space (right side, lateral to sternum) • “ I am auscultating the:” Pulmonic: 2nd intercostal space (left side, lateral to sternum) • “ I am auscultating the:” ERBS point 3rd intercostal space (left side (lateral to sternum) • “ I am auscultating the:” Tricuspid: 4th intercostal space (left side, lateral to sternum) • “ I am auscultating the:” Mitral: 5th intercostal space, midclavicular line (where apical pulse is present) Auscultate with Bell • “ I am auscultating the:” Aortic: 2nd intercostal space (right side, lateral to sternum) • “ I am auscultating the:” Pulmonic: 2nd intercostal space (left side, lateral to sternum) • “ I am auscultating the:” ERBS point 3rd intercostal space (left side (lateral to sternum) • “ I am auscultating the:” Tricuspid: 4th intercostal space (left side, lateral to sternum) • “ I am auscultating the:” Mitral: 5th intercostal space, midclavicular line (where apical pulse is present) State findings: heart auscultated at 5 points (aortic, pulmonic, erbs point, tricuspid, mitral) with both the diaphragm and the bell, no murmurs present upon auscultation, S1 is louder at the apex, S2 is louder at the base. ABDOMEN Patient will need to lay flat for this, please lay the exam table flat and pull out the leg support platform. 14.1 subjective abdomen question (have you had any abdominal discomfort recently?) 15.Inspect (instruct patient to remove shirt/top) squat to look at eye level

State Findings: abdomen is symmetrical, contour is flat/round, color is even, scars/lesions/ striae (present/not present) 16.Auscultation (bowel sounds, starting in the right lower quadrant) State findings: bowel sounds are present in all 4 quadrants 17.Percussion State findings: tymphany is the predominant sound across the abdomen with dullness heard over the liver (dense organ) 18.Palpation State findings: no tenderness or abnormal masses felt, abdomen is smooth upon palpation PERIPHERAL VASCULAR SYSTEM (still have your patient lying down) 19.1 subjective peripheral question (have you noticed any edema recently) Hand hygiene, apply gloves 20.Palpate pulses (radial, brachial, posterior tibial, dorsalis pedis) State findings: all pulses are present upon palpation +2 bilaterally, not bounding or thready 21.Assess temperature, texture, moisture and skin integrity • Using back of hands, palpate bilaterally starting at the top of the shoulder and working down the arm, then start at upper thigh and work down to feet State findings: skin is clean, dry, intact, skin is warm with smooth texture, no moisture, no ulcers/swelling/lesions/inflammation present in upper and lower extremities 22.Assess for edema on the upper on the upper and lower extremities. Rate edema on a scale of 0-4. • Use both hands, start at the shoulder, use the backs of the hands and palpate downwards. Press near the joints (wrist) and palpate the ankles (press down and release) • To grade edema, based on the time it takes for the skin to go back to normal. (look up edema grading) State findings: no edema present in the upper and lower extremities bilaterally 23.Assess capillary refill (upper and lower extremities) • Ask patients to stick out both hands, grab each index finger bilaterally and press on nailbed for 1 sec, color should turn white and back to red within 3sec • Grab both feet, and press on both big toes bilaterally for 1sec, color should return within 3sec State findings: capillary refill is positive, returns to normal in less than 3sec Keep gloves on! 2nd part of neuro exam!! 24.Assess for sensation in upper and lower extremities (with light touch) (This is the 2nd part of the neuro exam!!!)

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Using a cotton ball, have patient close eyes. Start bilaterally in upper arms near clavicle, press the cotton ball down the arm in 6 inch increments to till you reach the hands • Start again at the upper thigh and work your way down to the foot (again pressing the cotton ball down the leg in 6 inch intervals) State findings: touch sensation intact bilaterally in the upper and lower extremities 25.Motor strength: assess in the upper and lower extremities (Rate:0-5) • Start with the upper arms, stretch them outward so they are straight, have the patient lift up as you push down to create resistance • Have the patient lift down as you push up to create resistance • Have the patient form a 90 degree angle like a halfway bicep curl, pull and push against resistance • Next have the patient squeeze your hand, cross two fingers before they squeeze to limit injury •

Next test the legs, have patient kick leg outward while you push to provide resistance, have patient bend leg backward while you push forward to provide resistance • Foot test, have patient bend forward (pressing on the gas) while you push back to create resistance (plantar flexion/plantar extension) State findings: motor strength intact, rated +5 strength bilaterally in the upper and lower extremities MUSCULAR SYSTEM 26.Ask 1 subjective question (muscular system) (do you have any muscular pain or weakness?) 27.Perform egress test (place the step stool back into the exam table) • Sit up x3 (patient uses own hands to push up off of exam table 3 times, the nurse will stand in front of the patient with arms stretched on each side of patient to prevent fall) • March in place 3x (patient will stand up and march in place, knees to abdomen and sit back down) • Patient will stand up and pace back and forth 5 feet 3 times, (nurse will follow the patient to prevent falling with arms stretched out) State findings: patient is able to walk independently (negative egress test) 28.Assess gait and posture • Have patient wall to the front of the room and back State findings: patient’s gate is rhythmic and purposeful, posture erect, arms sway evenly bilaterally Finally: do hand hygiene, state that you would lower the bed down to its lowest setting, call light in hand • Ask can I get you anything else right now?

State that you are done test out!

Some different ways to remember cranial nerves!...