Maria Hall
NURS 242
NURS242 Health Assessment Lab
Head-to-Toe Check-off Documentation
General Survey
Appearance reflective of age. Well developed, well-nourished woman, neatly dressed and well groomed.
Oriented to person, place, time, and situation. Affect content. Speech clear and responds appropriately.
No acute distress at this time. Moves all extremities well, gait balanced and coordinated, no limping
noted. HT, WT, VS.
Integumentary
Right upper arm tender from recent influenza injection. Skin even in color, warm, dry, no edema,
positive turgor, no suspicious lesions or masses throughout body. Hair clean, evenly distributed. Nails of
upper and lower extremities all 10 digits are pink, smooth, with brisk capillary refill, no clubbing. Sharp
and soft sensations present in upper and lower extremities bilaterally.
Head and Neck
Head normocephalic, erect, and midline noted. Facial expression symmetrical and appropriate. No
scars, lesions, masses, or abnormal movements noted. Nasolabial folds and palpebral fissures
symmetrical. Cervical lymph nodes and thyroid not palpable. No neck vein distension noted bilaterally.
Cranial nerve V present through sensation of light touch to face bilaterally. Cranial nerve VII present
through symmetrical facial movements of frowning, smiling, closing eyes, and lifting eyebrows. Motor
function of opening of jaw. Cranial nerve XI present as demonstrated by shoulder and neck shrug
against hands.
Eyes
Cranial nerve II evidenced by Snellen chart. Reads with 20/20 in OS, OD and OU. Near vision intact
bilaterally. Eyes symmetrical bilaterally, parallel alignment. Eyelashes evenly distributed bilaterally. No
edema, dryness, tearing, or excessive eye drainage noted bilaterally. Conjunctiva clear, pink and moist,
no lesions noted bilaterally. Sclera white, intact, no lesions or scars bilaterally. Cornea clear bilaterally.
Iris round, symmetrical with no blood or bulging noted bilaterally. Smooth conjugate movement of eyes
in all directions, equal palpebral fissures without eyelid lag or nystagmus noted bilaterally. Cranial
nerves III, IV, and VI intact. PERRLA noted bilaterally.
Ears
Bilateral auricle, mastoid area, and tragus without tenderness, masses, lesions or edema noted. Gross
hearing intact bilaterally. Cranial nerve VIII present through whisper test. Negative Romberg test.
Nose
Nose and septum midline, symmetrical. No deformities, edema, or flaring noted bilaterally. Nasal
mucosa moist with scant mucus present bilaterally. Nares patent. Frontal and maxillary sinuses
nontender with resonant tone bilaterally.
Mouth
Lips midline, symmetrical, skin intact without lesions, pink and moist. No unusual odors noted. Teeth
white, not loose, with good occlusion, and in good repair. Tongue, gingivae and oral mucosa pink, moist,
and intact, no lesions noted. Tongue midline with full mobility, cranial nerve XII present. Pharynx, hard
and soft palate pink and intact, bilateral tonsils pink, symmetrical, +1, no lesions or exudates noted,
symmetrical rise of uvula, positive swallow reflex(CN IX and X). Parotid and submandibular glands
nontender and nonplapable bilaterally.
Pulmonary
Respiratory rate quiet and symmetrical with regular rhythm and depth bilaterally A/P. Supra- and
subclavicular lymph nodes nonpalpable, no tenderness noted. Equal excursion A/P, no lag. Tactile
fremitus equal bilaterally P. Lungs clear A/P bilaterally to auscultation. No crackles, wheezes, or rubs
noted.
Cardiovascular
No JVD noted bilaterally 45 degree angle. Carotid pulses 2+ pliable and soft, equal, no bruit on
auscultation bilaterally. Positive pulsation noted at apex. Brisk capillary refill <3s upper lower ext. 10
digits. No varicosities or edema in face and upper lower ext. noted bilaterally. Radial and pedal pulses 2+
equal bilaterally. Apical and radial pulses without deficit when sitting. Heart rhythms auscultated at
sitting and supine. S1 noted at aortic area, rhythm regular no murmurs. S2 noted at pulmonic area no
murmurs. S3 and S4 no murmurs or extra heart sounds noted.
Abdomen
Abdomen soft, nontender, flat, symmetrical, no bulges, pulsations, or hernias noted x4 quads. No
increased venous pattern or ascites, scars, rashes, or discoloration noted x4 quads. Upon auscultation,
med-pitched bowel sounds x4 quad. No bruits, hums, or rubs noted x4quad. Tympany x4 quad, dullness
over organs noted. Organs nontender upon percussion. Spleen non palpable. No palpable lymph nodes
in inguinal area bilaterally.
Urinary
Costrovetebral angles and flanks symmetrical bilaterally P, uniform color throughout. CVA non-tender
upon percussion bilaterally. Kidneys non palpable. Bladder symmetrical, not distended. Resonance
upon percussion.
Neurological
Mental status is alert; orientated to person, time, place, and situation. Affect content and cooperative.
Attention and concentration functional. Able to respond correctly to answers, demonstrating proper
language expression, comprehension, memory, and thinking skills. Cranial nerves II-XII present as
stated previously. Moves all extremities well, gait balanced and coordinated, no limping noted. Posture
erect. Negative Romberg test. Negative Babinski reflex. Graphesthesia and stereognosis intact
bilaterally.
Musculoskeletal
Gait balanced and coordinated. Posture erect and symmetrical. Following joints assessed: TMJ, neck,
spine, shoulders, elbows, wrists, fingers (all 10 digits), hips, knees, ankles, and toes (10 digits). All joints
without heat, redness or swelling, no crepitus or grinding noted. All joints performed full active ROM. No
misalignments or tenderness at all Spinous processes. Arm muscle strength rated at 5 bilaterally. Leg
muscle strength rated at 5 bilaterally.
1. Risk for impaired skin integrity related to influenza injection administered previous day. Upper
right arm tenderness noted during assessment.
2. Deficient knowledge related to unfamiliarity with information resources. Unknown effects of
influenza injection.