Advanced Nursing Practice Field Experience. Comprehensive Health Assessment Documentation Form
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1 Date: Advanced Nursing Practice Field Experience Comprehensive Health Assessment Documentation Form Patient Information Patient Initials Age Sex Chief Complaint History of Present Illness (HPI) Medications 7 attributes of a symptom: location, quality, quantity/severity, timing, setting, remitting/exacerbating factors, associated manifestations Allergies 1
2 Medical HX (PMH) Childhood Adult Surgical Ob/Gyn Psychiatric Vaccinations Flu Date: Pneumovax Date: Tetanus Date: Family HX (specify family member affected/age at death) Social HX HTN Renal dz Born in: DM Thyroid dz Education: Ca Suicide Occupation: MI/CAD Alcoholism Family situation: CVA Substance abuse TB Interests/Hobbies: 2
3 Review of Symptoms (ROS) List findings, or check as negative. (If you have a positive finding, then describe its seven attributes in the HPI or PMH) Concerning Symptom Findings General Skin Head Eyes Ears Nose/ Sinuses Throat Neck Breasts Wgt Δ; weakness; fatigue; fevers Rash; lumps; sores; itching; dryness; color change; Δ in hair/nails Headache; head injury; dizziness Vision Δ; corrective lenses; last eye exam; pain; redness; excessive tearing; double vision; blurred vision; scotoma Hearing Δ; tinnitus; earaches; infections; discharge Colds; congestion; discharge; itching; hay fever; nosebleeds Bleeding gums; dentures; last dental exam; sore tongue; dry mouth; sore throats; hoarse Lumps; swollen glands; goiter; pain; neck stiffness Lumps; pain; discomfort; nipple discharge Pulmonary Cough productive/non-productive; hemoptysis; dyspnea; wheezing; pleuritic pains Cardiac G/I Chest pain or discomfort; palpitations; dyspnea; orthopnea; PND; edema Appetite Δ; jaundice; nausea/emesis; dysphagia; heartburn; pain; belching/flatulence; Δ in bowel habits; hematochezia; melena; hemorrhoids; constipation; diarrhea; food intolerance 3
4 Urinary G/U (General) Male G/U Frequency; nocturia; urgency; dysuria; hematuria; incontinence MALES: caliber of urinary stream; hesitancy; dribbling Sexual habits; interest; function; satisfaction; use of birth control methods; HIV exposure Discharge from or sores on penis; testicular pain/masses Female G/U Peripheral Vascular Musculoskeletal Neuro Heme Endo Psych Menarche; frequency/duration of menses; dysmenorrhea; PMS symptoms: bleeding between menses or after intercourse; LMP Vaginal discharge; itching; sores; lumps Menopause; hot flashes; postmenopausal bleeding; Claudication; leg cramps; varicose veins; hx of blood clots Muscle or joint pain; joint stiffness Syncope; seizures; weakness; paralysis; numbness/tingling; tremors; involuntary movements Hx of anemia; easy bruising or bleeding; blood transfusions Heat or cold intolerance; excessive sweating; polydipsia; polyphagia; polyuria; glove or shoe size Nervousness/anxiety; depression; memory changes; suicide attempts 4
5 General Findings and Physical Exam General Observations Does patient appear to be their stated age? Level of consciousness Skin color Nutritional status Posture and position Obvious physical deformities Mobility: gait, use of assistive devices, ROM of joints, no involuntary movement Facial expression Mood and affect Speech: articulation, pattern, content and appropriate, native language Hearing Personal hygiene Measurements and Vital Signs Weight Height BMI Radial pulse: rate rhythm 5
6 Respirations: rate depth Blood pressure (indicate if sitting or lying) Temperature (if indicated) Pain assessment Skin Hands and nails Color and pigmentation Temperature Moisture Texture Turgor Presence of lesions? Head and Face Scalp Hair Cranium Face (cranial nerve VII) Temporal artery and temporomandibular joint Maxillary sinuses and frontal sinuses Eyes Visual fields (cranial nerve II) 6
7 Extraocular muscles, corneal light reflex, and cardinal positions of gaze (cranial nerves III, IV, VI) External structures Conjunctivae, sclerae, and corneas Pupils Describe the purpose of an Opthalmascope for assessing the eyes Ears External ear Any tenderness? Purpose of the otoscope Test hearing (cranial nerve II) and conduct the voice test Explain the Weber and Rinne tests Nose External nose Patency of nostrils Describe the purpose of the speculum evaluate nasal mucosa, septum, and turbinates 7
8 Mouth and Throat Lips and buccal mucosa Teeth and gums Tongue, hard palate, and soft palate Tonsils Uvula (cranial nerves IX, X) Tongue (cranial nerve XII) Neck Symmetry, lumps, and pulsations Cervical lymph nodes Carotid pulse (bruits if indicated) Trachea ROM (cranial nerve XI) Thyroid gland Chest and Lungs: Posterior and Lateral Thoracic cage configuration Skin characteristics Symmetric expansion Tactile fremitus Lumps or tenderness Spinous process Percussion over lung fields CVA tenderness 8
9 Breath sounds Adventitious sounds Chest and Lungs: Anterior Respirations and skin characteristics Tactile fremitus, lumps, and Tenderness Percuss lung fields Breath sounds Upper Extremities ROM and muscle strength Epitrochlear nodes Discuss the process for assessing breasts and axilla Neck Vessels Jugular venous pulse Presence of jugular venous distension Heart Precordium: pulsations and heave Apical impulse and PMI Precordium and thrills Apical rate and rhythm 9
10 Heart sounds Abdomen Contour, symmetry, skin characteristics, umbilicus, and pulsations Bowel sounds Vascular sounds Percussion Liver span in right MCL Spleen Light and deep palpation Palpation of liver, spleen, kidneys, and aorta Inguinal Area Femoral pulse Inguinal nodes Lower Extremities Symmetry, skin characteristics, and hair distribution Pulses: Popliteal posterior tibial dorsalis pedis Temperature and pretibial edema Toes 10
11 ROM and Muscle Strength Ankles and feet Neurologic Sensation: face arms hands legs feet Position sense Stereognosis Cerebellar function (finger to nose) Cerebellar function (heel to shin) Deep tendon reflexes: biceps triceps brachioradialis patellar achilles Babinski reflex Musculoskeletal Walk across room heel to toe Walk on tiptoes, then walk on heels Romberg sign Shallow knee bend ROM of spine 11
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