NURA 304 Health Assessment
Health Assessment Validation Tool
Health Assessment Validation Tool
Refer to the health assessment validation guidelines for additional information.
PRIVACY/SAFETY/PURPOSE
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15 points
Wash hands
Gather supplies needed for the exam and bring them to the bedside
Greet patient & identify the patient by checking the armband and using 2 identifiers
Create and maintain an appropriate environment
 Provide privacy throughout the exam
 Introduce self and purpose of exam
 Indicate confidentiality (information only shared with health care team)
Utilize effective communication skills /explain procedures
Position patient appropriately being sure they are as comfortable as possible
Wear appropriate attire--Don gloves and/or PPE (when indicated)
Organize assessment (supplies, procedures, time management)
ABBREVIATED/INTEGRATED BEDSIDE ASSESSMENT
2
1
2
3
1
1
1
4
70 points
WHEN OBSERVING OR ASKING QUESTIONS YOU MUST VERBALIZE YOUR FINDINGS/OBSERVATIONS
General Survey (overview of patient) – VERBALIZE FINDINGS
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Observe physical development- patients actual age contrasted to how they appear
Observe body build, weight and height and posture
Observe level of hygiene, grooming and dress
Observe behavior, comfort level or signs of distress, and non-verbal signs
Is the patient’s speech clear, can they hear, and what is their primary language?
Mental/Neuro Status
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Observe movement of extremities (state if they are smooth and controlled)
Test symmetric muscle strength (hand grip, feet)
Observe gait (walking to BR or in hall)
Observe balance (sitting and standing- Romberg test for standing)
Respiratory
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1
1
1
1
1
8 points
Orientation to person, place, time
PERRLA (Pupils Equal, Round, Reactive to light & Accommodation) [cranial nerve III, IV, VI]
Assess eyes for convergence
Musculoskeletal
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5 points
Observe color of face, lips and nail beds
Assess respiratory rate and rhythm
Look at characteristics of respirations (pattern, depth, work of breathing)
Assess breath sounds (bilaterally, anterior & posterior all fields)
3
4
1
7 points
1
2
2
2
9 points
2
1
2
4
Cardiac/Heart
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10 points
Assess apical pulse rate and rhythm
Auscultate for extra sounds (A, P, T, M with diaphragm & bell)
2
8
Peripheral Vascular
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Palpate temperature of arms, hands, legs and feet
Assess capillary refill (upper & lower extremities--bilaterally)(fingernails & toenails)
Palpate pulses (upper & lower extremities--bilaterally) (R, PT, DP)
Gastrointestinal (Abdomen)
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Observe appearance (flat, rounded, distended) and for pulsations
Auscultate bowel sounds (4 quadrants)
Palpate for tenderness (light palpation)
Ask patient about bowel movement patterns (frequency, color, amount)
Genitourinary (observation/inquiry)
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Ask patient about voiding pattern (normal frequency, do they have a catheter)
Ask or observe characteristics of urine (color, odor, appearance)
Integumentary (Skin / Hair/ Nails)
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2
2
3
6 points
1
2
2
1
2 points
1
1
9 points
Assess skin integrity (intact or areas of breakdown, ant & post surfaces); lesions/wounds 4
Assess skin turgor (elastic, tenting, diaphoretic)
2
Assess overall color (normal for race, pale, cyanotic, flushed, jaundiced, erythema)
1
Assess mucus membranes (pink, moist)
2
Pain
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7 points
7 points
State you would observe patients facial expression and posture / non-verbal’s
Ask patient to rate pain on a scale of 0-10
Ask patient location (where is pain?)
Ask patient a minimum of 4 characteristics (describe the pain)
FOCUSED/PROBLEM ORIENTED ASSESSMENT
1
1
1
4
15 points
1. Integumentary (Skin / Hair/ Nails):
 Ask patient if they are experiencing any skin problems or changes in skin condition
 Assess for dryness or moisture anteriorly and posteriorly
 Assess for lesions or wounds anteriorly and posteriorly (description, location)
 Assess finger nails and toe nails (shape, texture, color, capillary refill)
 Assess hair & scalp (distribution, texture, inhabitants)
2. Respiratory:
 Ask patient “Do you have a cough? Is it productive?”
 Ask patient “Do you have any difficulty breathing— any chest tightness or shortness of breath?”
 Ask patient if they smoke; How much? How long?
 Assess O2 saturation / oxygen requirement
 Inspect chest configuration
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Observe use of accessory muscles
Percuss over anterior & posterior chest
Assess chest expansion (excursion)
3. Peripheral Vascular:
 Ask patient if they are experiencing any signs of swelling in legs or feet.
 Assess for edema (facial, upper & lower extremities-- bilaterally)
 Inspect lower extremities for color, temperature, hair distribution, vascularity
 Assess for sensation
4. Cardiovascular:
 Ask patient if they have been experiencing any chest pain
 Ask patient if they have a history of palpitations, high BP, or high cholesterol
 Assess for neck vein distention
 Inspect for heave or lift; palpate for thrill
 Palpate carotids (individually)
 Auscultate with bell
 Palpate abdominal aorta
 Auscultate with bell
5. Musculoskeletal:
 Functional ROM: Ask patient if they are able to complete ADLs such as dress yourself, brush teeth & hair
 Assess for joint swelling and tenderness (palpate elbows, fingers, knees, toes)
 Inspect & palpate spine
 Palpate joints & muscle groups for symmetry
o Shoulders→elbows→wrists→fingers
o Hips→knees→ankles→toes
 Assess muscle strength (bilaterally against resistance)
o Shoulders→arms→wrists→fingers
o knees→ankles
 Assess ROM (bilaterally)
o Shoulders→elbows→wrists→fingers [cranial nerve XI]
o Hips→knees→ankles
6. Neuro:
 Ask patient if they have any numbness or tingling in any of your extremities
 Ask patient if they have any problems with headaches, dizziness, falling
 Assess memory
o Immediate
o Recent (24 hr memory)
o Remote (past dates & historical accounts)
 Assess light touch sensation [cranial nerve V]
o Face
o Upper extremities
o Lower extremities
 Assess sharp/dull discrimination [cranial nerve V]
o Upper extremities
o Lower extremities
 Assess Deep Tendon Reflexes (DTRs):
o Biceps tendon
o Triceps tendon
o Patellar reflex
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7. Ears:
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Nose:
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o Plantar reflex
Assess swallowing [cranial nerve IX, X]
Assess coordination (Tandem walking)
Ask patient if they wear a hearing aid
Ask patient if they have had any recent changes in their hearing
Inspect & palpate pinna & tragus
Whisper test [cranial nerve VIII]
Assess patency
Inspect nasal mucosa and nasal septum
Olfactory (smell) function [cranial nerve I]
Mouth / Throat:
 Ask patient if they wear dentures; inspect teeth
 Have patient stick out tongue and move side to side or say “light, bright, dynamite” [cranial nerve XII]
 Inspect throat - Observe for rise of uvula [cranial nerve IX, X]; tonsils
Eyes:
 Ask patient: Do you wear glasses? All the time or reading glasses?
 Ask patient: Have you had any recent changes in your vision?
 Inspect distribution of eyelashes & brows
 Inspect lids for swelling, ptosis [cranial nerve III, IV, VI]
 Inspect sclera
 Fields of gaze [cranial nerve III, IV, VI]
8. Cranial nerves:
 CN I—sense of smell
 CN II—Snellen chart or reading to assess vision
 CN III—6 fields of gaze / ptosis / PERRLA
 CN IV—6 fields of gaze / ptosis / PERRLA
 CN V—contraction of masseter muscle & light touch sensation over face
 CN VI—6 fields of gaze/ ptosis / PERRLA
 CN VII—symmetrical movements of face (puff cheeks, smile, frown)
 CN VIII—whisper test
 CN IX—swallowing & uvula rise with “aah”
 CN X—swallowing & uvula rise with “aah”
 CN XI—turn head against resistance, shrug shoulders against resistance
 CN XII—test tongue movement by saying “light, bright, dynamite” or push tongue against cheek
Grade: _________
Student: ________________________________ Student signature: __________________________________
Faculty: _________________________________ Date: _______________________________________
Revised FEK 3/19