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Health assessment

A health assessment is a plan of care that identifies the specific needs of a person and how those needs will be addressed by the healthcare system or skilled nursing facility. Health assessment is the evaluation of the health status by performing a physical exam after taking a health history. It is done to detect diseases early in people that may look and feel well.

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Please note that this comes from Seidel: Mosby’s Guide to Physical Examination, 7th Edition. It is intended for nurses studying health assessment. It is a checklist for a complete physical examination. VS (vital signs) Temperature, pulse, respirations, BP (blood pressure), height, weight GENERAL APPEARANCE Age, race, gender, posture, gait MENTAL STATUS Consciousness, cognitive ability, memory, emotional stability, thought content, speech quality SKIN Color, integrity, hygiene, turgor, hydration, edema, lesions, hair distribution and texture, nail texture, nail base angle HEAD Scalp, temporal arteries, deformities NECK Trachea (position, tug), range of motion (ROM), carotid bruit, jugular venous distention (JVD), thyroid, lymph (head and neck) EYES Pupils (PERRLA), eyelids, conjunctivae, sclerae, EOMs (CN III, IV, VI), light reflex, visual fields, funduscopy (CN II), acuity (CN II), nystagmus EARS Deformities, lesions, discharge, otoscopy (canal, TM), hearing (Rinne, Weber, CN VIII) NOSE Mucosa, septum, turbinates, discharge, sinus area swelling/tenderness MOUTH AND THROAT Lips/teeth/gums, tongue (CN XII), mucosa, palates, tonsils, exudate, uvula, gag reflex (CN IX, X) CHEST/LUNGS Shape, movement, respirations (rate, rhythm), expansion, accessory muscles, tactile fremitus, crepitus, percussion tone, excursion, auscultation (clear, wheeze, crackles, rhonchi, rubs) BREASTS Contour, symmetry, nipples, areolae, discharge, lumps/masses, lymph (axillary, supraclavicular, and infraclavicular) HEART PMI (previous myocardial infarction), lifts, thrills, rate, rhythm, S1, S2, splitting, gallops, rubs, murmurs, snaps BLOOD VESSELS Cyanosis, clubbing, edema, peripheral pulses, skin, nails ABDOMEN Contour, symmetry, skin, bowel sounds, bruits, hum, liver span, liver border, tenderness, masses, spleen, kidneys, aortic pulsation, reflexes, percussion tone, costovertebral angle (CVA) tenderness, femoral pulses, lymph (inguinal) MALE GENITALIA Pubic hair, glans, penis, testis, scrotum, epididymis, urethral discharge, hernias FEMALE GENITALIA External lesions or discharge, Bartholin and Skene glands, urethra, vaginal walls, cervix (position, lesions, cervical motion tenderness), uterus, adnexa RECTUM/PROSTATE Sacrococcygeal and perineal areas, anus, sphincter tone, rectal walls, masses, fecal occult blood test (FOBT) Male: Prostate Female: Rectovaginal septum, uterus MUSCULOSKELETAL Posture, alignment, symmetry, joint heat/swelling/color, muscle tone, ROM, strength NEUROLOGIC CN II-XII, rapid alternating movements, finger-to-nose, sensation, vibration, stereognosis, motor system, gait, Romberg, deep tendon reflexes (DTRs), superficial reflexes CRANIAL NERVES (CN) I: Smell II: Visual acuity, visual fields, funduscopy III, IV, VI: Eyelid opening EOMs: IV up and out, VI lateral, III all others V: Corneal reflex, facial sensation (3 areas), jaw opening, bite strength VII: Eyebrow raise, eyelid close, smile, taste VIII: Rinne, Weber IX, X: Gag reflex, palate elevation, phonation XI: Lateral head rotation, neck flexion, shoulder shrug XII: Tongue protrusion, lateral deviation strength

Contributed by Christine Ruff

Please know that this comes from Seidel: Mosby’s Guide to Physical Examination, 7th Edition. It is for nurses studying health assessment. It is a checklist for taking a complete medical history before starting a physical examination. History — Subjective Data ID (identification) Age, gender, DOB (date of birth) CC (chief complaint) Reason for seeking care HPI (history of the present illness) O - onset L - location D - duration C - character A - aggravating/associated factors R - relieving factors T - temporal factors S - severity Medications, treatments PMH (past medical history) General health, surgeries, hospitalizations, illnesses, immunizations, medications, allergies, blood transfusions, emotional status/psychiatric history PERSONAL HISTORY Cultural background, marital status, occupation, economic resources, environment HEALTH HABITS Tobacco, alcohol, illicit drugs, lifestyle, diet, exercise, exposure to toxins HEALTH MAINTENANCE Last PE (physical exam), diagnostic tests (date, result, follow-up), self-exams (breast, genital, testicular), last Pap smear, mammogram FAMILY HISTORY (Parents, siblings, children) Cancer, DM (diabetes mellitus), hypertension, heart disease, stroke REVIEW OF SYSTEMS GENERAL Fever, chills, malaise, fatigue/energy, night sweats, desired weight DIET Appetite, restrictions, vitamins, supplements SKIN, HAIR, NAILS Rash, eruptions, itching, pigment changes HEAD AND NECK Headaches, dizziness, head injuries, loss of consciousness EYES Blurring, double vision, visual changes, glasses, trauma, eye diseases EARS Hearing loss, pain, discharge, vertigo, tinnitus NOSE Congestion, nosebleeds, postnasal drip THROAT AND MOUTH Hoarseness, sore throat, bleeding gums, ulcers, tooth problems GASTROINTESTINAL Indigestion, heartburn, vomiting, bowel regularity/changes LYMPH Tenderness, enlargement ENDOCRINE Heat/cold intolerance, weight change, polydipsia, polyuria, hair changes, increased hat, glove, or shoe size FEMALE LMP (last menstrual period), age at menarche, gravity, parity, menses (onset, regularity, duration, symptoms), sexual life (number of partners, satisfaction), contraception, menopause (age, symptoms) MALE Puberty onset, erections, testicular pain, libido, infertility BREASTS Pain, tenderness, lumps, discharge CHEST AND LUNGS Cough, sputum, shortness of breath, dyspnea on exertion, night sweats, exposure to TB CARDIOVASCULAR Chest pain, palpitations, number of pillows, edema, claudication, exercise tolerance HEMATOLOGY Anemia, easy bruising GENITOURINARY Dysuria, flank pain, urgency, frequency, nocturia, hematuria, dribbling MUSCULOSKELETAL Joint pain, heat swelling NEUROLOGIC Fainting, weakness, loss of coordination MENTAL STATUS Concentration, sleeping, eating, socialization, mood changes, suicidal thoughts

Contributed by Christine Ruff

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