D116 Comprehensive Advanced Health Assessment Techniques Checklist

D116 Comprehensive Advanced Health Assessment Techniques Checklist

Student Name

Western Governors University

D116 Advanced Pharmacology for the Advanced Practice Nurse

Prof. Name:

Date

Advanced Health Assessment for the Advanced Practice Nurse

The Comprehensive Advanced Health Assessment Techniques Checklist outlines critical assessment areas and individual items for advanced practice nurses to evaluate accurately. This tool ensures that candidates demonstrate proficiency in various examination techniques, contributing to holistic patient care.

Health History

When obtaining a health history, it is essential to gather detailed and relevant information systematically. The assessment should include:

• Chief complaint

• History of present illness with a focused orthopedic review

• Current medications

• Allergies and any associated reactions

• Past medical history

• Vaccination status

• Family medical history

• Social history

• Review of symptoms

These components allow the practitioner to build a thorough patient profile, which is foundational for diagnosis and treatment planning. The health history section accounts for 9 points.

Measurement and Vital Signs

Assessing basic measurements and vital signs includes asking the patient about their weight and accurately measuring pulse, respiration rate, and blood pressure. These vital signs offer essential baseline data on the patient’s physiological status. This section has 2 points available.

Skin Assessment

Skin examination is comprehensive, focusing on the following characteristics:

• Hands and nails

• Skin color and pigmentation

• Temperature

• Moisture

• Texture

• Turgor

• Presence of any lesions

Such detailed inspection aids in identifying dermatological conditions or systemic illnesses manifesting through skin changes. This portion carries 7 points.

Head and Face Examination

Assessment of the head and face requires inspection and palpation of:

• Scalp, hair, and cranium

• Facial symmetry and function, including cranial nerve VII

• Temporal artery and temporomandibular joint

• Maxillary and frontal sinuses

These evaluations help detect abnormalities such as infections, vascular issues, or neurological impairments. This section is worth 6 points.

Eye Examination

Evaluating the eyes involves several tests to assess cranial nerves II, III, IV, and VI, including:

• Visual fields

• Extraocular muscle function

• Corneal light reflex

• Cardinal positions of gaze

• External structures and conjunctivae

• Pupillary response

Proper eye examination is vital in detecting neurological and ocular diseases. This segment offers 7 points.

Ear Examination

Examination includes:

• External ear inspection

• Palpation for tenderness

• Conducting the voice test to assess cranial nerve VIII

Ear assessment helps diagnose infections or hearing impairments. This section is allocated 3 points.

Nose Assessment

The nose is evaluated for:

• External structure

• Patency of the nostrils

This brief but essential assessment ensures nasal airway function, contributing 2 points.

Mouth and Throat Examination

Examination of the oral cavity covers:

• Lips and buccal mucosa

• Teeth and gums

• Tongue

• Hard and soft palate

• Tonsils

• Uvula, related to cranial nerves IX and X

• Tongue motor function (cranial nerve XII)

Oral assessment is crucial for detecting infections, lesions, and neurological deficits. This area is valued at 7 points.

Neck Assessment

Key aspects include:

• Symmetry, presence of lumps or pulsations

• Cervical lymph node palpation

• Carotid pulse and auscultation for bruits

• Tracheal position

• Range of motion and muscle strength (cranial nerve XI)

• Thyroid gland palpation

This examination identifies vascular, lymphatic, and musculoskeletal disorders. It carries 6 points.

Chest and Lung Examination

Posterior and lateral chest and lungs involve assessing:

Anterior chest and lungs assessment focuses on:

Heart Examination

A thorough cardiac assessment includes:

• Precordium inspection for pulsations and heaves

• Apical impulse palpation

• Thrills over the precordium

• Apical rate and rhythm evaluation

• Auscultation of heart sounds

This detailed examination is crucial for detecting cardiac abnormalities, and it accounts for 5 points.

Upper Extremities

Assessment includes:

• Range of motion and muscle strength

• Palpation of epitrochlear lymph nodes

This ensures musculoskeletal and lymphatic health, contributing 2 points.

Neck Vessels

Evaluation focuses on:

• Jugular venous pulse

• Jugular venous distension

These findings assist in diagnosing cardiovascular conditions such as heart failure and venous congestion. This section is worth 2 points.

Abdominal Examination

The abdomen is assessed systematically for:

Inguinal Area

Focused on:

• Femoral pulse palpation

• Inguinal lymph node palpation

This helps detect vascular and lymphatic pathologies, contributing 2 points.

Lower Extremities

Assessment includes:

Musculoskeletal and Neurological Examination

This complex evaluation covers:

• Ankles and feet inspection

• Sensory testing of the face, arms, hands, legs, and feet

• Position sense and stereognosis

• Cerebellar function tests (finger-to-nose, heel-to-shin)

• Deep tendon reflexes: biceps, triceps, brachioradialis, patellar, Achilles

• Babinski reflex

• Meningeal signs including nuchal rigidity, Kernig sign, Brudzinski sign, and jolt accentuation headache

• Cranial nerves I and V

• Romberg test

This comprehensive neurological exam ensures integrity of sensory, motor, and cerebellar functions. It holds 12 points.

Hips and Knees: Range of Motion and Muscle Strength

Functional assessment involves:

• Walking across the room heel-to-toe

• Walking on tiptoes, then on heels

• Performing shallow knee bends

• Touching toes

• Assessing spine range of motion

These tests help identify musculoskeletal weaknesses or neurological impairments and account for 5 points.

Presentation Skills

Effective communication is assessed by observing if the candidate:

• Engages with the patient respectfully

• Explains each procedure clearly

• Advises appropriate follow-up

• Thanks the patient and leaves the room politely

This professional conduct is valued at 3 points.

Focused Orthopedic Examination

This section includes evaluations of:

• Scoliosis

• Low-back pain

• Shoulder function

• Wrist function

• Knee joint stability

Each part must be performed successfully to pass, though it is not included in the total 100-point score. Passing requires achieving at least 85 points in scored areas and successful completion of all orthopedic components.

Scoring and Competency

The assessment uses a points system with a maximum of 100 points plus bonus points. Candidates must score a minimum of 85 points on the scored sections and pass the focused orthopedic exam to achieve an overall passing grade.

Summary Table of Assessment Areas and Points

References

• Jarvis, C. (2020). Physical Examination and Health Assessment (8th ed.). Elsevier.

• Bickley, L. S., & Szilagyi, P. G. (2021). Bates’ Guide to Physical Examination and History Taking (13th ed.). Wolters Kluwer.

D116 Comprehensive Advanced Health Assessment Techniques Checklist

• Seidel, H. M., Ball, J. W., Dains, J. E., & Benedict, G. W. (2021). Mosby’s Guide to Physical Examination (9th ed.). Elsevier.