Name
Western Governors University
D222 Comprehensive Health Assessment
Prof. Name
Date
Hello, my name is ________. This document presents a detailed account of my comprehensive health assessment video submission. In this submission, I conducted a structured and systematic physical examination on a volunteer patient. The main aim of this assessment was to demonstrate proficiency in clinical observation, measurement, communication, and physical examination techniques that meet professional nursing standards.
This section introduces the volunteer patient involved in the assessment.
Verification Process
To begin, I confirmed the patient’s identity by asking:
“Could you please state your full name and date of birth for verification purposes?”
After verifying the patient’s identity, I requested consent:
“Do I have your permission to record and conduct a full physical health assessment today?”
Upon receiving consent, the assessment proceeded. Throughout the process, the importance of patient consent and confidentiality was emphasized in accordance with ethical healthcare guidelines (American Nurses Association, 2023).
Initial Assessment (Sitting Position)
The assessment began with a health interview and baseline measurements while the patient was seated upright. This positioning ensures accuracy and consistency in physiological readings.
| Question | Response |
|---|---|
| Do you have any allergies? | None reported |
| Are you currently taking any medications? | No medications at this time |
| What is your height and weight? | Height: ____ cm, Weight: ____ kg |
| Calculated BMI | ____ (Indicates normal, healthy weight) |
| Do you have any pain? | No pain reported (0/10 on pain scale) |
| Are you physically active? | No |
| Average sleep per night? | Approximately 6 hours |
| Do you get annual physical check-ups? | Yes |
Radial Pulse: Palpated for 30 seconds and multiplied by two. The rate, rhythm, and amplitude were normal, with a strength of +2 and regular rhythm.
Respirations: Observed for 30 seconds and multiplied by two. Breathing was even and unlabored, without accessory muscle use.
Blood Pressure: Measured with the patient seated, feet flat, legs uncrossed. Readings were within normal limits, indicating adequate cardiovascular function.
The skin was inspected for color, texture, and integrity. No abnormalities like erythema, cyanosis, or jaundice were noted. Palpation revealed the skin to be warm, dry, and smooth, indicating good hydration and circulation.
The hands showed no signs of swelling or dryness, and skin turgor was normal, reflecting appropriate hydration. Nail inspection revealed no clubbing, thickening, or discoloration, which suggests healthy peripheral perfusion and oxygenation.
The head and face were examined for symmetry, tenderness, lesions, or trauma. The scalp was clear of scaling or scars. The patient reported no pain or discomfort.
Cranial Nerve VII (Facial Nerve) Examination
The patient was asked to perform various facial movements—raising eyebrows, closing eyes tightly, smiling, frowning, and puffing cheeks. Symmetrical facial muscle tone was observed, indicating intact Cranial Nerve VII.
Eye examination focused on alignment and symmetry. Eyelids were free from swelling or ptosis. The sclera was white, and the conjunctivae appeared pink and moist.
Pupillary Response (PERRLA)
Pupils were equal, round, and reactive to light and accommodation. They measured about 3 mm at rest and constricted properly in response to light.
Cranial Nerve II and Peripheral Vision Test
The confrontation test showed intact peripheral vision, confirming proper function of Cranial Nerve II (Optic Nerve).
Extraocular Muscles (Cranial Nerves III, IV, VI)
Ocular movements were smooth and coordinated across six cardinal fields of gaze. No signs of nystagmus or strabismus were detected.
Corneal Light Reflex
Symmetrical reflections of light in both eyes confirmed proper ocular alignment.
Both ears were symmetrical, with no lesions, drainage, or tenderness. The patient denied hearing loss, tinnitus, or dizziness. External auditory structures appeared healthy and intact.
The nasal structure was straight and symmetrical. There was no discharge or inflammation, and both nostrils were patent. The patient denied any history of nosebleeds (epistaxis).
| Question | Response |
|---|---|
| When was your last dental visit? | Recent dental check-up |
| How often do you brush and floss? | Brushes twice daily and flosses regularly |
Oral Examination
Lips and mucous membranes were moist and pink without lesions. Gums and tongue appeared healthy, with good dentition and no bleeding reported.
Cranial Nerves IX and X (Glossopharyngeal and Vagus)
The uvula elevated in the midline as the patient said “ah,” and the gag reflex was intact, indicating normal cranial nerve function.
The neck was symmetric with no masses or lymphadenopathy. The trachea was midline, and carotid pulses were palpable without bruits. Cranial Nerve XI (Accessory Nerve) was tested via head resistance and shoulder shrug, both strong and symmetrical.
Posterior Thoracic Assessment
The thoracic cage was symmetric, expanded normally, and was non-tender. Lung fields were clear bilaterally with no adventitious sounds.
Anterior Thoracic Assessment
Respiratory movement was even, with no accessory muscle use. Breath sounds were clear across all lobes.
The apical pulse was auscultated at the fifth intercostal space along the midclavicular line for a full minute. Heart sounds S1 and S2 were distinct, regular, and without murmurs or extra sounds. All five cardiac landmarks showed normal findings.
Both arms had a full range of motion and equal strength. Pulses were +2 bilaterally, and capillary refill was under two seconds, indicating efficient peripheral circulation.
Jugular Vein
No jugular venous distention was observed when the patient was positioned at a 45-degree angle.
| Method | Findings |
|---|---|
| Inspection | Slightly rounded, symmetrical abdomen, no bulges |
| Auscultation | Normoactive bowel sounds in all quadrants |
| Palpation | Abdomen soft, non-tender, no masses detected |
| Percussion | Tympanic sounds present, no dullness |
Both legs appeared symmetrical with normal color and warmth. No edema or ulcers were noted. Peripheral pulses (femoral, popliteal, posterior tibial, dorsalis pedis) were +2 bilaterally, and capillary refill was less than two seconds.
Deep Tendon Reflexes
Reflexes at the biceps, triceps, brachioradialis, patellar, and Achilles tendons were brisk and symmetrical, reflecting intact neurological function.
Sensation Test
The patient correctly identified sharp and soft touch stimuli on various extremities, confirming intact peripheral sensation.
Coordination and Spine
The spine was midline with normal curvature and full range of motion. The patient demonstrated coordinated motor function by walking heel-to-toe, on tiptoes, and on heels without imbalance.
Sleep Hygiene
The patient reported approximately six hours of sleep per night. Education emphasized the importance of obtaining 7 to 8 hours of quality sleep nightly to support cardiovascular health, cognitive function, emotional regulation, and immune system efficiency (Centers for Disease Control and Prevention [CDC], 2023).
Physical Activity
The patient was encouraged to increase physical activity to meet the World Health Organization’s recommendation of at least 150 minutes of moderate-intensity aerobic exercise weekly, along with two days of strength training. Suggested activities included brisk walking, cycling, and swimming to boost cardiovascular endurance and musculoskeletal strength (World Health Organization, 2023).
A follow-up appointment with a primary healthcare provider was recommended for ongoing health monitoring and management.
The health assessment was successfully completed with all findings within normal limits. The patient tolerated the examination well, and no abnormal results were detected. This process highlighted the significance of systematic observation, effective communication, and patient-centered care in holistic nursing assessments.
American Nurses Association. (2023). Code of ethics for nurses with interpretive statements. https://www.nursingworld.org/practice-policy/nursing-excellence/ethics
Centers for Disease Control and Prevention. (2023). How much sleep do I need? https://www.cdc.gov/sleep/about_sleep/how_much_sleep.html
World Health Organization. (2023). Physical activity fact sheet. https://www.who.int/news-room/fact-sheets/detail/physical-activity
