Health Assessment Script
Identification:
1. Knock, walk into lab room and wash hands
a. “Good morning, my name is ___ and I am going to be your nurse today”
i. Shake hands with the patient
b. “Can you please tell me your name, date of birth, and where you are?”
Basic Neuro Exam:
1. Assess level of consciousness
a. “Patient is awake, alert, and oriented times 3”
b. “Patient scores a 15 on the Glasgow coma scale with a score of 4 for eye
opening, 5 for verbal response, and 6 for motor response”
c. Excuse me i’m going to wash my hands
2. Assess Pupils (PERRLA)
a. Pupils, Equal, Round, React to, Light, Accommodate
i. React to light:
1. “I’m going to look at your eyes now. Can you stare at the wall
behind me while I shine this light in your eyes?”
a. Use penlight to move the light from side to side on each
eye to check for pupil constriction - left eye, down, right
eye (not across face)
ii. Accommodate:
1. “Now, please follow my pen with your eyes”
a. Use finger/pen to move finger toward nose to check if
eyes move with the finger to focus
iii. “Patient’s pupils are equal, round, and reactive to light and
accommodation”
b. “Next, can you look at the tip of my pen again without moving your head?”
i. 6 Cardinal Fields of Gaze
1. Upper to left lower
2. Left upper to right lower
3. Right side to Left Side
c. “Patient’ extraocular eye muscles are intact. No nystagmus noted.”
3. Mouth
a. “Now can you open your mouth? Stick out your tongue? Lift your tongue up?”
i. Observe using Penlight
1. “Tongue and mucosal membranes are pink and moist. No lesions
noted. All teeth are intact with no signs of decay.”
b. Tongue depressor, press on tongue
i. “Can you open your mouth and say ‘aaaah’?”
1. “Uvula rises at midline showing that Vagus nerve (Cranial Nerve
10) is intact”
c. Respiratory
i. “Are you having any shortness of breath or cough?”
1. “There is no presence of respiratory distress”
ii. “I’m now going to listen to your lungs. Please take a deep breath through your
mouth each time you feel my stethoschope on your skin”
a. ANTERIOR; 6 SPOTS
b. LATERAL; 3 SPOTS, BOTH SIDES. START UNDER ARMPIT
c. POSTERIOR; 8 SPOTS
i. Make sure you move across before you move down. Listen for
entire breath
iii. “Lung sounds are clear and equal to auscultation bilaterally in the anterior, lateral,
and posterior fields.”
iv.
“There is no presence of crackles or wheezing.”
d. Cardiovascular
i. “I am going to check your radial pulse”
1. 30 seconds for pulse. 30 seconds for rr
a. “Pulse is regular and ___.”
b. “Respirations are regular and 14”
ii. “I am now going to begin listening to your heart sounds with the Diaphragm of my
stethoscope. I may be listening for a while.”
1. “ I will first listen to the aortic valve which is located at the second
intercostal space, right sternal border.”
a. “S1 and S2 are present”
2. “Now, listening to the pulmonic valve, which is located at the second
intercostal space, left sternal border.”
a. “S1 and S2 are present”
3. “The tricuspid valve, located at the 4th intercostal space left lower sternal
border.”
a. S1 and s2 are present
iii. “I am now going to listen to your heart sounds with the bell of my stethoscope”
1. “I am listening to the aortic valve located at the second intercostal space,
right sternal border.”
a. “No murmurs present”
2. “I’m listening to the pulmonic valve located at the second. Intercostal space,
right sternal border. “
a. “No murmurs are present”
3. “Now, I’m listening to the tricuspid valve located at the 4th intercostal space,
left sternal border.”
a. “No murmurs are present”
4. “Lastly, I’m listening to the mitral valve located at the 5th intercostal space,
midclavicular line.”
a. “No murmurs are present”
iv. Apical Pulse  Mitral valve
1. “I’m now going to palpate the apical impulse
a. Feel for 30 seconds
i. “There are no thrills or heaves present.”
2. “I am now going to listen to your apical impulse”
a. MUST LISTEN FOR ONE MINUTE
i. “Apical pulse is 84 and regular”
v. Carotid Artery
1. “Next, I’m going to listen to your carotid artery with the bell of my
stethoscope.”
a. “Can you take a deep breath in, let it out, and hold for me?”
i. Listen to 3 on each side
1. “No bruits identified, bilaterally”
2. “Now, I’m going to feel your carotid arteries.”
a. Palpate on each side, one at a time
i. “Carotid arteries are palpable bilaterally and are +2, ”
e. Abdomen
i. “I’m going to look at your stomach now. Can you lay on your back and lift your
shirt?”
1. Appearance:
a. “Abdomen is flat with no contour. There are no lesions,
discolorations, tattoos, or scars”
2. Auscultation:
a. Right lower quad, right upper quad, left upper quad, left lower quad
b. “I am now going to listen to your bowel sounds with the diaphragm
of my stethoscope”
i. “Bowel sounds are all normal, active, and present in all 4
quadrants”
3. Percussion
a. “I am now going to percuss your stomach”
i. Tap knuckle on middle finger with middle finger of opp hand
b. “Tympani noted in all quadrants except the Right Upper Quadrant
where dullness is noted over the liver.”
4. Palpation
a. “Now, I am going to lightly press on your stomach.”
i. Light palpation all 4 quadrants
1. “No guardi awwww kkthkuykkk ty yhumukyuuyk, or
masses palpated in all 4 quadrants”
b. “This time, I’m going to be pushing a little deeper”
i. Deep (2 hand) palpation
1. “No guarding, tenderness, or masses palpated in all
for quadrants”
5. Liver
a. “I am going to feel over your liver now. Please take a deep breath”
i. Stand at right shoulder, hooking method
b. “The liver is not palpable”
4. Peripheral Vascular
a. Upper Extremities
i. Feel skin using back of hands
1. “Skin is pink and warm to touch. Hair growth even bilaterally.”
ii. Feel brachial (elbow) and radial (wrist) pulses
1. “Pulses are regular and +2 bilaterally.”
iii. Cap refill
1. “Capillary refill is less than 2 seconds bilaterally”
b. Lower Extremities
i. Feel skin
1. “Skin is pink and warm to touch. No hair growth present, have
you recently shaved your legs?”
ii. Feel pulses, Dorsalis pedis pulse (top of foot) and Posterior tibial pulse
(Inside of patient’s ankle)
1. “Dorsalis pedis pulses are +2 and regular bilaterally. Posterior
tibial pulses +2 and regular bilaterally”
iii. Press for Edema
1. “No edema present and no lesions are noted”
5. Musculoskeletal
a. Upper
i. “I am going to test the strength of your hands”
1. “Can you squeeze my fingers as hard as you can?”
ii. “Next, I’m going to test the strength of your arms”
1. “Please raise your arms like this”
a. “Don’t let me push against your arms”
b. “Don’t let me pull against your arms”
iii. “Grip strength, arm strength and resistance is strong and equal
bilaterally. Graded +5
b. Lower
i. “Now I’m going to assess your leg strength”
1. “Don’t let me push against them”
2. “Don’t let me pull against them”
ii. “Leg raising strength and resistance is strong and equal bilaterally.
Graded 5+”
c. Reflexes
i. “I’m going to test your reflexes in your biceps”
1. Use triangle part, hit thumb
ii. “Lastly, I’m going to test your reflexes in your patellar”
1. Use other side, hit knee
iii. “Patellar reflexes are present and +2 bilaterally”