D222 Health Assessment
Required equipment: stethoscope, a penlight, a watch, a BP cuff (manual or automatic), a reflex hammer, a cotton swab (soft touch), and a pen cap/ paper clip (sharp touch).
PART 1
(BEGIN WITH THE VOLUNTEER IN A SEATED POSITION FACING THE CAMERA WITH YOU TO THE SIDE OR BEHIND THEM.)
- My name is Whitney. I am a Registered Nurse. I understand you are here for a physical exam. Is it okay if I complete a comprehensive assessment on you?
- Can you tell me your Name? DOB? What year is it? What city are you in?
- What is your height and weight?
- Pt is Alert and Oriented The posture is upright. Facial expression, mood, and affect are appropriate for the situation. Speech is clear. Personal hygiene is clean.
I will now check your Vital Signs.
- I am going to assess your bpm RADIAL PULSE for 30 seconds and multiply by 2.
- Pulse is 64 and
- Now I will count your Respirations for 30 seconds and multiply by 2
- Respiratory rate is 16 labored, even,
- I am now going to check your Blood Pressure. First sitting down then standing
- BP sitting: / . BP standing: / .
- I am going to assess your current Pain Level on a 0-10 scale.
SKIN ASSESSMENT
I’m assessing the color and pigmentation of your skin on your arms, legs, face, and body. I’m checking for
pallor, erythema, cyanosis, and jaundice.
- I’m checking that your skin color is consistent with your ethnic background, and smooth
- I am now assessing the temperature of your
- It is warm bilaterally, with no swelling or edema
- Your skin moisture is not dry, it is consistent with your ethnic No lesions were noted.
- I am now assessing the texture of your skin. I am assessing whether it is smooth, firm, or even,
- I am now assessing your skin I am assessing whether your skin is non-tenting bilaterally.
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