Health Assessment

IN PARTIAL FULLFILLMENT FOR THE REQUIREMENTS

IN THE SUBJECT HEALTH ASSESSMENT

Submitted to:

Mr. Jefferson Colon

Submitted by:

Julian, Jana Rio M.

BSN I-IV

1. Performing Hand Hygiene

*Wash your hands for a minimum of 15 to 20 seconds following the correct sequence or areas

to be washed first. Rinse properly and dry off using a clean towel. If possible, try not touching the faucet

or any handle in the washroom.

2. Gather all equipment need

*Be sure to clean the equipment before going to the client. The equipment varies depending on

what area will be assessed.

3. Identify client and explain the procedure

*The rationale of doing this is to make sure that you have the correct client that will be assessed

and giving him/her knowledge on what you are about to do.

4. Instruct client to void before doing the exam

*The rationale of doing this is to make sure that the area involved will be assessed properly and

to make client more comfortable with an empty bladder.

5. Assist client to change into hospital gown and provide privacy

*Wearing a hospital gown is the most convenient attire when assessing a client. Make sure that

you will be giving privacy as to maintain dignity of client.

GENERAL SURVEY

6. Physical Appearance

Normal Abnormal Other Cases:

Age Appears like stated age Appears older or

younger

Turner’s Syndrome

Gender Sexual development is

appropriate to gender

and age

Delayed or advanced

puberty

Level of Consciousness Alert, oriented,

responds appropriately

Confused, drowsy,

lethargic

Skin Color Skin tone is even, intact

with no obvious lesions

Palor, Cyanosis,

Jaundice, Erythema

(redness), presence of

lesions

Facial Features Symmetrical with

movement

Immobile, mask-like,

asymmetric, drooping

Overall No signs of acute

distress

Respiratory signs:

Shortness of breath,

wheezing

Pain: Grimace,

holding/guarding body

part, knees drawn up

over the abdomen

7. Body Structure

Normal Abnormal Other Cases

Structure Height appears within

normal range, for age,

genetic heritage.

Excessively short or tall Gigantism: experienced

by children

Aromegaly: experienced

by people 18 >

Simmonds: low growth

hormone

Nutrition Weight appears within

normal range for

height, body build, fat

distribution.

Emaciated, Cachectic

(Tissue wasting), Obese,

Fat concentration in

face, neck, trunk, arms,

and legs

Cushing’s Syndrome:

Thin extremeties, with

buffalo hump

Symmetry Body parts look equal

bilaterally and are in

relative proportion to

each other.

Body parts are not

proportioned

Unilateral Atrophy: Loss

of muscle volume

Hypertrophy: Increased

muscle volume

Posture Clients stand

comfortably erect.

Stiff, tense, with fidgety

movement, shoulders

humped, looks

depressed

Position Client comfortably sits

on a chair or on the bed

with arms relayed at

the sides, head turned

to the examiner.

Client is curled up in

fetal position; leaning

forward with arm

braced on chair

Body Build and Contour Slender, medium build,

stocky or muscular.

Thin; muscle wasting;

obese

*Things to remember:

1. Endomorph: fat

2. Mesomorph: normal

3. Ectomorph: thin

8. Mobility


Gait Base is wide as the

shoulders; foot

placement is accurate

Exceptionally wide

base, staggered,

stumbling, limping with

injury

1. Spastic

2. Scissor

3. Propulsive

4. Steppage

5. Waddling

Range of Motion Full mobility of each

joint; movements are

Paralysis; jerky,

uncoordinated

deliberate and accurate movments

9. Behaviour


Facial expression Client maintains eye

contact, expressions are

appropriate to the

situation

Flat, depressed, angry,

sad, anxious

Mood and Affect Client is cooperative;

comfortable with

examiner; interacts

pleasantly.

Hostile, distrustful,

suspicious, crying

Speech Client speaks clearly;

stream of talking is

fluent, even; word

choice is appropriate

Difficulty in talking;

abnormal pitch or

volume; voice is hoarse

or whispered; slurred

speech; constant talking

Dress Clothing is appropriate

to the climate and age

group; looks clean and

fits the body;

Trousers are too large

and held by belt; looks

unclean;

Personal Hygiene Appears clean and

groomed; appropriate

for age, occupation, and

socio-economic group;

hair is brushed or

groomed.

Unkept hair; Absent

makeup

INTEGUMENTARY SYSTEM

10. Inspect skin for color, pigmentation, and lesions.


Color

Whitish pink, or brown

color; Depends on

race.

Cyanotic (bluish);

Jaundice (yellowish)

1. Pallor: decreased

visibility of normal

oxyhemoglobin

2. Carotenemia:

excessive carotene

3. Hyperemia:

increased blood

flow

4. Erythema: redness

of skin

5. Xanthoma Striata:

Yellowish

discoloration of

palmar and digital

creases

6. Addison’s disease:

bronze-like skin

due to deficit in

cortisol

7. Acanthosis

Nigricans:

brownish skin due

to use of steroids

and obesity

8. Albinism:

generalized

whiteness;

9. Vitiligo: absence of

melanin

10. Erythematosus:

“butterfly rash”

11. Cloasma and Linea

nigra: seen in

pregnant women

Temperature

For Palpation:

Palpate all

nonmucosal skin

surfaces using dorsal

surfaces of hands.

Warm and equal

bilaterally; hands and

feet maybe cooler

than rest of body.

Hyperthermia

11. Inspect hair distribution, texture, moisture all over the body.


Distribution Body is covered with

vellus hair; terminal

hair is found in

eyebrows, eyelashes,

scalp and in axilla and

pubic hair areas.

Absence of pubic hair

(unless purposely

removed)

1. Traction Alopecia:

hair loss in linear

formation

2. Hirsotism: excess

facial and body hair

3. Trichotillomania:

areas of broken-off

hair in irregular

patterns

Texture

Evaluate texture using

Feels smooth, even,

and firm except when

Roughness on exposed

areas; Hyperkeratosis

finger pads, check

abdomen and medial

surfaces of arms first.

there is significant hair

growth.

and silk-like

Moisture

For Palpation:

Palpate all non-

mucous membrane

skin surfaces using

dorsal surfaces of

hands and fingers.

Skin is dry with

minimum

perspiration, moisture

vary from one area to

another.

Excessive dryness;

profuse sweating

1. Xerosis

2. Diaphoresis

12. Inspect nails for characteristic, color, texture, shape and configuration.

*Note for capillary refill.

Color

Abnormalities:

1. Leukonychia: white striations in the nail bed

2. Leukonychia totalis: nail bed is white due to hypercalcemia

3. Melanonychia: brown color of nail plate

4. Cyanotic: bluish nails

5. Splinter hemorrhage: red or brown linear streaks nail bed

6. Lindsey’s Nails: white proximal end and pink distal portion of nailbed

7. Onychomycosis: yellow or white hue

8. Terry’s Nails: whitish band

Shape and Configuration

Abnormalities:

1. Koilonychia: thin spoon nail with cuplike depression

2. Clubbing: Angle of nailbed is 160 degrees

3. Beau’s Line: transverse furrow in the nail plate

4. Oncholysis: separate of nail from nail bed

5. Caronychia: painful red swelling

6. Sublingual hematoma: purpura or ecchymosis under nail plate

7. Onychocryptosis: distal portion of nail plate is embedded in periungal tissue

8. Eggshell nails: curved under nail edge

9. Onychatrophia: nail atrophy or shrinking

10. Onychorrhixis: nail is split in lengthwise

11. Pterygium: abnormal cuticle that overgrows the nail

Texture

*Nailbase must be firm

*Clubbing is due to prolonged hypoxia (chronic bronchitis, emphysema, heart disease)

13. Palpate for temperature, texture and moisture.

Normal Abnormal

Temperature

Palpate all nonmucosal skin

surfaces using dorsal surfaces of

hands.

Warm and equal bilaterally;

hands and feet maybe cooler

than rest of body.

Hyperthermia

Feels smooth, even, and firm

except when there is significant

hair growth.

Roughness on exposed areas;

Hyperkeratosis and silk-like

Moisture

For Palpation:

Palpate all non-mucous

membrane skin surfaces using

dorsal surfaces of hands and

fingers.

Skin is dry with minimum

perspiration, moisture vary from

one area to another.

1. Xerosis

2. Diaphoresis

14. Perform skin turgor/skin pinch and mobility.

Procedure Normal Abnormal

Palpate skin turgor at dorsal

surface which reflects the skin’s

state of hydration

Should return to its original

contour rapidly. It takes about 1-

2 seconds.

Poor skin turgor; Does not go

back immediately.

HEAD AND FACE

15. Inspect the skull for shape, size, masses, nodules, and lumps.

Procedure Abnormalities

1. Have patient sit in a comfortably position.

2. Face the patient with client’s head in level

with yours.

3. Inspect for symmetry.

Normal Shape: Normocephalic

1. Hydrocephalus: enlargement of head

without enlargement of facial structure

2. Acromegaly: abnormal enlargement of

skull with bony facial structure

3. Craniosynostosis: abnormal shape of skull

at right angles

4. Anencephaly: absence of brain and skull

5. Microcephaly: circumference of head is

smaller than average.


Face Symmetrical; Palpebral

fissure should be equal

*Slight variations are

common

Structures are

deformed; Asymmetry

of face

Shape No edema;

Disproportionate

structures

Slanted eyes with inner

epicanthal folds; a short

flat nose and a thick

protruding tongue;

Facial skin is shiny,

contracted and hard;

face is immobile and

expressionless

Hypertelorism:

abnormally wide

distance between the

eyes.

16. Inspect face for symmetry~ CN5.

17. Perform test for CN7.

Facial Motor Exam Abnormalities

*Forehead and Upper lid Innervation

1. Eyebrow elevation

2. Forehead wrinkling

3. Frowning

4. Tight Closing of the eyes

*Lower Face innervation

1. Showing teeth

2. Whistling

3. Puffing cheeks

4. Natural smile

5. Test or inquire about Taste

Sensation

1. Unless bilateral lesion, does not affect

forehead

2. Mouth paralysis is overcome by

emotional expression

3. Ipsilateral forehead and lower face

paralysis

18. Inspect and palpate scalp, hair, and cranium.


Scalp Scalp should be pale

white to pink in light-

skinned people and

light brown in dark-

skinned people.

Infestation, dandruff Head lice (Pediculosis

Capitis)

Hair Dark to pale blonde Patches of gray hair

that are isolated or

occur in conjunction

with scar

19. Palpate temporal artery – CN5 Motor

20. Palpate frontal and maxillary sinuses for tenderness.

21. Percuss frontal and maxillary sinuses for tenderness.

22. Auscultate temporal artery for bruits.

EYES

23. Inspect eyebrows and eyelashes for hair distribution and alignment.

Normal Abnormal

Eyelashes

Eybrows

Symmetrical; evenly distributed;

bilateral

Absence of eyelashes; infection

near areas

24. Inspect lids for skin characteristics, color, and position.


Eyelids Symmetrical; client can

move both eyelids;

normal lid margins are

smooth with lashes

evenly distributed

Drooping; infections;

tumors; excessive

blinking; swelling

1. Lagophthalmos:

inability to bring

about complete lid

closure

2. Eyophthalmos:

disparity of

palpebral fissure

3. Enophthalmos:

disparity in size of

globe

4. Entropion:

inversion of lower

lid

5. Ectropion: eversion

of lower lid

6. Hordeolum: acute

inflammation

7. Chalazion: chronic

inflammation

8. Belpharitis:

bilateral

inflammation

25. Inspect bulbar and palpebral conjunctiva, note for color sclera and iris.

Normal Abnormal

1. Gently pull down

eyelashes and place a

sterile cotton-tipped

applicator above the lid

margin.

2. Gently exert downward

pressure.

3. Inspect Palpebral

Conjunctiva for infection

and swelling

4. Return eyelid to its

normal position.

Increased lacrimation; reddish

bulbar conjunctiva

Pinguecula: yellow nodule on the

nasal side of bulbar conjunctiva

Pterygium: unilateral/bilateral

triangle shaped encroachment

Sclera White sclera; small blood

vessels; tiny brown patches

Jaundice; bluish sclera

(Osteogenesis Imperfecta)

26. Inspect and palpate the lacrimal gland, asses for color, swelling and exudates.


Lacrimal apparatus No enlargement,

swelling, redness,

exudates; minimal

tearing

Mucopurulent

discharge; overflowing

tears (Epiphora)

1. Dacroadenitis:

acute

inflammation

2. Dacrocystisis:

inflammation and

painful swelling

beside nose and

near inner

canthus

27. Test for corneal reflex (Blinking and tearing)

Procedure

1. Instruct the client to look straight ahead.

2. Focus a penlight on the corneas from a distance of 12 to 15 inches away from

midline.

3. Observe location of reflected light on the cornea.

Normal Abnormal

Reflected light should be seen in the center of

each cornea

1. Strabismus: deviation of one eye

2. Esotropia: inward turning of the eye

3. Exotropia: Outward evading of eye

28. Inspect pupils for size, shape and symmetry.

Normal Abnormal

Pupils Black pupils, round, and of equal

diameter, ranging from 2-6mm;

brisk constriction to direct light;

1. Miotic Pupils (<2mm

constriction)

2. Mydriatic Pupils (>6mm

dilation)

Pupils with irregular shape

Asses Client’s

29. Direct and consensual reaction to light and accommodation.

30. Visual fields by confrontation (CN II).

31. Six cardinal gaze (EOM).

Normal Abnormal

Procedure:

1. Place client in sitting

position, facing you.

2. Place non-dominant

hand just under the

client’s chin as a

reminder to keep the

head still.

3. Ask client to follow an

object with eyes.

4. Move object through the

six fileds of gaze in a

smooth and steady

manner.

5. Note client’s ability to

move eyes in each

direction.

6. Move the object forward

5 inches away from face.

7. Observe for convergence

of gaze

Both eyes should move smoothly

and symmetrically in each of the

six fields of gaze

Lack of symmetrical mov’t;

abnormal eye mov’t;

1. Opthalmoplegia:

paralysis of one/more

optic muscles

2. Vertical gaze: paralysis

of upward gaze

3. Paralysis of horizontal

gaze

32. Asses visual acuity (Snellen’s)

Procedure

1. Ask client to remove corrective lenses if he/she wears them.

2. Cover one eye.

3. Ask him to read letters on one line going downward until he can no longer discern the letters.

EARS

33. Inspect and palpate auricle/pinna for color, symmetry, position, and palpate for tenderness.


External Ear Same color; pain Pale, cyanotic;

tenderness; edema

1. Microtia:

abnormally large

ears

2. Auricular

hematoma:

damaged/mutilat

ed ear.

3. Perichondritis:

edematous,

painful ear.

4. Carcinoma: tumor

on external ear

5. Battle’s sign:

hematoma behind

ear over mastoid

bone

34. Inspect external auditory canal for color, patency. Note color and gloss and state characteristics of

tympanic membrane.

35. Assess client’s hearing acuity (Voice whisper).

Normal Abnormal

Client is able to repeat 2 syllable word Client is unable to hear the word

36. Perform Weber’s Test.

Normal Abnormal

Client should perceive the sound equally in both

ears; No lateralization of sound is known as a

negative Weber’s Test.

Sound localizes on unaffected ear

37. Perform Rinne’s test.

Normal Abnormal

Air conduction is heard twice as long as bone

conduction when client hears through the external

auditory canal is no longer heard.

Client hears the sound longer through the bone

conduction.

NOSE

38. Inspect external nose for color, shape, size, flaring and discharges, deviations.

Normal Abnormal

Air can move through nostrils Air cannot move through nostrils

39. Inspect the nasal cavities for color, swelling, edema, discharges, growth with the use of nasal

speculum.

Normal Abnormal

Nasal Mucosa should be pink/dull; without

swellings or polyps

Red mucosa; swollen width copeus; clear water

discharge; edematous

40. Palpate for tenderness or mass.

Normal Abnormal

Client should experience no discomfort during

palpation; sinuses should be air filled, therefore

resonant to percussion

Nasal Polyps: Smoot, round masses that are pale

and shiny and are noted protruding from middle

meatus

Nasal Septal Perforation: nasal mucosa is inflamed.

41. Check for patency of both nostrils.

42. Check for CN 1 (Smell Test).

MOUTH AND THROAT

43. Inspect the outer lips for color symmetry, and texture. Palpate for lesions.

Normal Abnormal

Lips should be pink and moist with no lesions or

inflammation

Lips are pale; inflamed

1. Herpes Simplex

2. Chancre

3. Wart

4. Nodule

44. Examine oral mucosa, gums, teeth, using the tongue blade and penlight.


Oral Mucosa Color may vary

according to race;

should be moist,

smooth and free of

lesions

Inflamed; lesions 1. Leukoplakia:

leathery,

painless, white,

pointed-looking

palates

2. Apthous ulcer:

small, round

white ulcers.

3. Stomatitis:

reddish mucosa

4. Xerostoma:

excessive

dryness of

mucosa

Gums Lightly colored; gum

margins should be well

defined with no pockets

existing between gums

and teeth

Inflamed Gingivitis: red,

tender, swollen

and bleeding

gingiva

Teeth Presence of 32< teeth Absence/loss of teeth 1. Dental Carries:

white/black

patches on the

surface of the

tooth

2. Dead tooth:

darker in color

and insensitive

to cold

3. Hutchinson’s

Incissors: teeth

with serrated

edges

45. Inspect the outer lips for color, moisture, size, and position. Inspect the hard and soft palates.


Palate Hard and soft palates

are concave and pink;

hard palate has many

ridges, soft palate is

smooth

Infection 1. Torus Platinus:

bony ridge in

the middle of

hard palate

2. Palatine

Perforation:

hole in hard

palate

46. Inspects the uvula for position, Oropharynx for color.

47. Inspect the tonsils for color, discharge, and size.

48. Perform taste test (CN7- Sensory).

49. Palpates tongue for nodules and lumps.


Tongue is in midline of mouth,

dorsum of tongue is pink, moist,

ruoght.

Tongue is enlarged, red, smooth,

w/ absent papillae

1. Glossitis: reddish tongue

with absent papillae.

2. Candidiasis: thick, white,

crudlike coating on

tongue.

50. Note tongue movement and strength (CN 12).

51. Elicits the gag reflex (CN IX and X)

NECK

52. Inspect neck muscles and assesses head movement and strength (CN11)

Normal

Muscles of neck are symmetrical with head in a central position. Patient is able t move the head,

through a full range of motion.

53. Inspect and palpates for location of trachea.

54. Palpates thyroid gland to identify enlargement, nodule and tenderness.

Procedure:

1. Stand behind patient.

2. Have the patient lower the chin slightly.

3. Place your thumb at back of patient’s neck.

4. Move finger pads over tracheal ring.

5. Instruct patient to swallow- palpate for nodules or enlargement.

55. Palpate and identify lymph nodes.

56. Observes for carotid artery pulsation and jugular vein distention.

THORAX AND LUNGS

57. Inspects the size, shape and symmetry of the thorax and note for spinal deformities.


Chest Elliptical in shape with

lateral diameter that is

larger than the AP

diameter.

AP is larger than lateral

diameter

1. Barrel Chest:

the AP diameter

is equal to the

lateral diameter

2. Funnel Chest

(Pectus

Excavatum):

depression of

the sternum

3. Pigeon Chest

(Pectus

Carinatum):

forward

displacement of

the sternum

4. Scoliosis: lateral

curvature and

rotation of

thoracic and

lumbar spine

5. Kyphosis:

exaggerated

posterior

curvature of

thoracic spine

58. Palpate the posterior chest (Spinous process) for tenderness and spacing.

Normal Abnormal

Posterior Chest Muscle mass should be firm; no

lesions; non tender; movement

and pressure of chest against

your hands should feel smooth.

Tender; lesions; delay in

expansion may indicate

fibrotic/obstructive lung disease.

59. Assess for tactile fremitus.

Normal Abnormal

Symmetrical vibration a. Decreased/Absent fremitus: soft voice,

thick chest wall, COPD, pleural effusion

b. Increased fremitus: fluid in lungs or

infection

60. Note for diaphragmatic excursion (Posterior).

*Abnormal: Dull sounds

61. Percuss the posterior thorax.

Normal Abnormal

3-5 cm distance between marks and even on each

side. Right side maybe 1-2cm higher because of

the location of the liver.

Shortened excursion (lungs are not fully

expanding).

62. Performs respiratory excursion (Anterior).

63. Auscultate the chest using the systematic zigzag method (both anerior and posterior chest and

identifies the location and type of the normal breath sounds).

Normal Abnormal

Muffled sounds Sound is loud and more distinct

HEART

64. Simultaneously inspect and palpates the precordium for abnormal pulsations heaves/lifts ( using Z

technique)

Normal Abnormal

No visible pulsations, except at the PMI (Point of

Maximal Impulse) or where the apical pulse is

located, visible as a pulsation or thrust.

Neck distention and or visible pulsations in the

precordial area except @ the PMI.

65. Auscultates the aortic, pulmonic, tricuspid and mitral areas at proper locations for heart sounds

noting for S1 and S2 sounds; PMI.


S1- first heart sound (LUB);

S2-2nd

heart sound (DUB)

S3-normally present under 34

years and below

S4-may occur on young people

with thin chest wall

Chest pain indicates inadequate

myocardial tissue oxygenation;

pulse deficit

1. Dyspnea:

labored/difficulty in

breathing

2. Orthopnea:

breathlessness that

prevents client from

lying down

3. Fatigue: worse at night

due to decreased cardiac

output

4. Cyanosis/Pallor: due t

decreased CO that

results to decreased

tissue perfusion

5. Dependent Edema:

indicates heart failure

6. Jugular Vein Distention:

indicates heart failure

BREAST AND AXILLA

66. Inspect each breast and axilla while client’s hands are resting on her side, placed on hips, above the

head. Note for contour, size, symmetry, discolorations, and dimpling.


Smooth; w/o lesions; dense

breast tissue; nipple usually

everted out in the same

direction; no discharge

Increased vascularity of breast;

nipple discharge; scaling around

nipple

Gynecomstia: breast

enlargement for males.

67. Performs breast-self examination, palpates the breast in a systematic manner and notes for masses,

tenderness and texture.


Nodular and granular

consistency; inferior aspect of

breast is firm; non-tender

Lumps; unilateral granulation;

mass; itching; swelling;

tenderness

Peau d’ orange:

thickening/edema of breast

tissue/nipple with enlarged skin

pores.

68. Assess for lymph nodes. (Axillary)

Normal Abnormal

Non-tender; less than 1cm in diameter Fixed; more than 1cm; painful; enlarged; matted

together

ABDOMEN

69. Observe for the contour and inspect the symmetry of abdomen.

Normal Abnormal

Contour: Flat, rounded/scaphoid

Contours:

1. Flat

2. Rounded/Convex

3. Scaphoid/Concave

4. Protruberant

Protruberant abdomen (normal in pregnant

women)

*Ascites: accumulation of fluid in abdominal

cavity.

Symmetry: Without bulging/masses Assymetrical

70. Check umbilicus for contour or hernia, observe skin characteristics.

Normal Abnormal

Located at the center; inverted or protruding;

clean and free of inflammation or drainage

Displaced umbilicus; For non preggo’s: indicates an

abdominal mass/distended urinary bladder

Hernia: for children

71. Note for pulsations, visible peristalsis, and movement.

72. Auscultate for bowel sounds in the four quadrants. Note the character and frequency.

Normal Abnormal

5-30/min or 10/sec (Borborygmi); no vascular

sounds/friction rubs; irregular, gurgling and high

pitched bowel sounds

Hypoactive: 1/15 sec

Hyperactive: 1/sec

73. Percuss the abdomen.

Normal Abnormal

a. Tympany: stomach

b. Dullness: liver and spleen

Dullness: distended urinary bladder or ascites

Liver: approximately 5-10cm (2-4 in)

Size at midsternal line: 4-9 cm (1.5-3 inc)

Spleen: tympanic sound Dull sound

74. Palpate surface and deep areas, assess size, location, consistency of abdominal organs, screen mass

or tenderness-light/deep.

Normal Abnormal

Stomach: Soft, smooth, non-tender, pain free Masses; tumors; or obstructions during palpation

Liver: Non-palpable; lower border of the liver is

smooth, firm and non-tender

Pain; nodules occur with cirrhosis

Spleen: Non palbable Splenomegaly

75. Perform special procedure (rebound tenderness, Murphy’s sign, Iliopsoas muscle, Obturator test)

MUSKULO-SKELETAL- UPPER EXTREMITIES

76. Inspects nail beds for color, shape, texture and surrounding tissues.

77. Performs the capillary test/blanch test.

Normal Abnormal

Nail bed should regain usual color in 1-2 seconds. Nail bed regains own color after more than 2

seconds

78. Inspect muscles for size, notes for symmetry, palpates for muscle tone while client is active and then

passive, palpate joints.

Normal Abnormal

Symmetrical hands and arms; absence of muscle

wasting; no edema; no tenderness, redness or

increased heat

Assymetry or deformity of fingers in rheumatoid

arthritis

79. Test for muscle strength bilaterally.

Normal Abnormal

Fingers: Equal strength on both hands

Wrist joint: No enlargement or discomfort or pain;

symmetrical muscle strength

Enlargement along joints or discomfort/pain;

Unequal strength which may indicate weakness on

either side

*Stereognosis: able to identify an object

80. Check for ROM asking client to move selected body parts and names exercises done.

Normal Abnormal

Full, without difficulty Presence of pain

81. Elicits reflexes (Biceps, Triceps, Brachioradialis)

Normal

Biceps Reflex 2+

Contraction of biceps muscles with flexion of the

elbow

Triceps Reflex 2+

Contraction of triceps muscle with extension of

forearm

Brachio-radialis or supinator Reflex 2+

Flexion and supination of forearm

82. Conducts fine motor test.

83. Conducts light touch sensation and notes for pain and temperature sensation.

Normal Abnormal

Light Touch Sensation: Client is able to feel the

touch as light or soft on either side

Decreased/absent sensation

Pain Sensation: Client is able to tell the sensation

as sharp or dull

Client has difficulty feeling sensation

Conducts tactile discrimination

84. One and two point

Normal Abnormal

Acceptable standard of distance that a client can

no longer feel the distance bet/ two points or

object is 5 millimeters

Increased distance between the 2 points felt

suggests lesions in sensory cortex

85. Stereognosis

Normal

Client is able to identify the given object correctly.

86. Extinction phenomenon

Normal Abnormal

Client is able to feel both touches and is able to

directly point the correct location of touch

Feels only one stimulus suggests lesions of the

sensory cortex

87. Graphestesia

Normal Abnormal

Able to identify number Inability to identify the number written which may

indicate a lesion on the sensory cortex

LOWER EXTREMITIES

88. Inspect legs together, note skin color, distribution, venous pattern, size, lesions.

89. Measure calf circumference along legs down to the feet.

Normal

Symmetrical and equal circumference, size, and length.

90. Palpate skin temperature along legs down to the feet.

Normal

No inflammations or enlargement or pain

91. Assess for Romberg, tandem walking, heel to shin.

Normal

Able to do this in a straight line without losing balance

92. Assess for Homan’s sign.

93. Check for pretibial edema.

94. Check for reflexes.

Reflex Normal

Quadriceps reflex/Patellar reflex Quadriceps contract, lower leg extends

Achilles reflex Plantar flexion

Plantar/Babniski reflexes Plantar flexion without toe fanning or great toe

dorsiflexion

95. Check for muscle strength.

Normal

Toes Good muscle strength

Both legs No limitation of movement

Health Assessment

Documents

correct client

contour client

depressed client

dignity of client

normal range

body structure normal

mobility normal base

legs body parts