CNUR 107 Health Assessment Systems Assessment Worksheet 2025 PDF

# CNUR 107: Introduction to Health Assessment Systems Assessment Worksheet, 2025 ## Table of Contents - Integumentary System: 2 - Respiratory System: 4 - Cardiovascular System: 5 - Peripheral Vascular System & Lymphatic System: 6 - Gastrointestinal System: 8 - Genitourinary System: 9 - Neurologica...

# CNUR 107: Introduction to Health Assessment Systems Assessment Worksheet, 2025 ## Table of Contents - Integumentary System: 2 - Respiratory System: 4 - Cardiovascular System: 5 - Peripheral Vascular System & Lymphatic System: 6 - Gastrointestinal System: 8 - Genitourinary System: 9 - Neurological System: 10 - Musculoskeletal System: 12 - Eyes, Ears, Nose, Mouth & Throat: 13 - Head to Toe: 15 ## Note: This is a summary of what is expected for each system. The how is provided in Jarvis (2024). ## Subjective Questions For all systems, asking subjective questions allows the nurse to obtain additional information, focus your assessment, planning, intervention, and evaluation. Subjective questions should be pertinent and relevant. - Current symptoms - Related medical/surgical history - Other medical/surgical history - Medications (prescription, OTC, herbal remedies, recreational) - Medication compliance - Health/social/ environmental risk factors - Family History # Integumentary System ## Subjective - History of skin disease - Change in pigmentation or mole - Dryness/moisture/pruritus - Bruising/rash/lesions - Sun exposure - Medications - Nutrition/hydration - Work exposure ## Objective: ### Inspection - Color - Lesion - Moles (ABCDE) - Vascularity/bruising - Rash - description - Skin breakdown - Dressings - Hair - Color - Distribution - Lesions - Nails - Shape - Contour - Color ### Palpation - Temp - Moisture - Texture - Thickness - Turgor/Mobility - Edema - Hair - Texture - Distribution - Lesions - Nails - Consistency - Cap Refill ### Risk Assessment - Braden Risk Scale (Remember this is to assess risk for skin breakdown. Not assess healing potential.) - Pressure Reduction Surfaces - Properly used # Respiratory System ## Subjective - Cough- productive? If so, color and amount, timing - Smoking- pack year history - Environmental exposure - SOB/SOBOЕ - Chest pain with breathing - History of Respiratory infections - Self-care behaviours - Supplemental O2 use  ## Objective: ### Inspection: Posterior - Shape and configuration - Position of person - Skin color and condition ### Palpation: Posterior - Tenderness, skin temperature, moisture, superficial lumps/masses - Symmetrical lung expansion - Tactile fremitus using “99” or “blue moon” ### Percussion: Posterior ### Auscultation: Posterior ### Inspection: Anterior - Shape and configuration - Note facial expression - Assess LOC - Skin color and condition - Assess quality and rate of respirations - Assess if any accessory muscles being used ### Palpation: Anterior - Tenderness, skin temperature, moisture, superficial lumps/masses - Symmetrical lung expansion - Tactile fremitus using “99” or “blue moon” ### Percussion: Anterior ### Auscultation: Anterior and Lateral - Oxygen: RA or supplemental type and amount **See end of document for lateral lung auscultation** *Calculating pack year history:* - # of cigarettes/day x years smoking - Noting that there are 20 cigarettes in a pack *i.e.* 3/4 packs per day for 40 years, 15 per day. - 20 per pack x 40 years = 30 pack years # Cardiovascular System ## Subjective: - Chest pain- at rest/with exertion - Dyspnea/orthopnea - Nocturia - Cough - Fatigue - Cyanosis or pallor - Edema - Past cardiac history - Family cardiac history - Cardiac risk factors ## Objective: ### Neck Vessels - **Inspect:** Jugular venous pulse - **Auscultate:** Carotid arteries - **Palpate:** Carotid arteries ### Precordium - **Inspect:** Pulsations- apical impulse - **Palpate:** Across precordium (omit palpation of apical pulse) ### Auscultate: (Diaphragm and Bell) - Assess heart sounds first with diaphragm, repeat with bell (APE to Man) traditional pattern on page 523 (Jarvis, 2024). - S1 and S2, location of where it is heard loudest. - Comment on the rhythm and abnormal sounds if present - Rhythm at apex - Apical pulse for 1 minute - Check apical pulse against radial pulse, noting perfusion of all beats (pulse deficit) - Rolling the patient to their left side and sitting them up and forward may help to detect or further assess abnormal heart sounds that will be introduced in CNUR 203. This is done to displace the heart forward and closer to the chest wall. *Jarvis is not specific about HOW to auscultate the precordium. Please follow these instructions and the traditional pattern on page 523 (Jarvis, 2024).* # Peripheral Vascular System & Lymphatic System ## Subjective: - Leg pain/cramps - Skin changes on arms/legs - Swelling in extremities - Lymph node enlargement - Medications - Diabetes/hypertension control ## Objective: ### PV: #### Arms (upper extremities) - **Inspect:** - Color - Symmetry - Nails (clubbing/ angle) - Skin lesions/breakdown - **Palpate:** - Edema - (grade) - Temperature - Texture - Turgor - Capillary refill - **Pulses:** Use Doppler if can't find by palpation - Radial - Brachial #### Legs (lower extremities) - **Inspect:** - Color - Symmetry - Hair distribution - Skin lesions\breakdown - Nails (clubbing/angle) - Venous pattern - **Palpate:** - Edema (grade) - Temperature - Texture - Turgor - Capillary refill - **Pulses:** Use Doppler if can't find by palpation. - Femoral - Popliteal - Posterior tibial - Dorsalis pedis ### Lymphatic: - **Inspect:** Swelling and edema of upper and lower extremities - **Palpate:** - Edema - (if so, grade) - Accessible lymph nodes using pads of fingers - landmark appropriately - Head & neck (page 288-290) - Epitrochlear (page 557) - Axillary (page 441) *For all pulses: Assess and note rhythm and amplitude. Must describe anatomical landmarks for all pulses. Assess simultaneously except for carotid and popliteal which is one at a time. Bilateral assessment still required.* # Gastrointestinal System ## Subjective: - Appetite/food intolerance - Dysphagia - Abd pain - N & V - Bowel habits including last BM - Abd history - Abd surgery - Medications - Nutritional assessment - food and fluids ## Objective: - Position patient supine with pillow under knees - **Inspect abdomen (use tangential light as needed):** - Contour - Symmetry - Umbilicus - Skin - Pulsation/Movement - Demeanor of the patient - **Auscultate**: do this BEFORE percussion and palpation - Bowel sounds - Vascular sounds - **Percuss** - **Palpation:** - 1cm light palpation - Check any tube placement for drainage and insertion site integrity # Genitourinary System ## Subjective: - Voiding - regularity, amount, colour, odour - Fluid intake - Medications - Gender Reassignment ## Males: - **History:** Kidney disease, kidney stones, flank pain, UTI's, prostate dysfunction, erectile dysfunction - **Urinary:** Frequency, urgency, nocturia, dysuria, trouble starting stream, straining, dribbling, Urine colour, clarity, odour, UTI - **Penis:** Pain, lesions, discharge - **Scrotum:** Pain, lumps - **TSE** - how often performed - **Sexual History:** sexually active, contraception/ Type, STI history - self and partner(s) ## Females: - **History:** Menstrual – LMP, Menarche, Cycle, Dysmenorrhea, Menorrhagia - **Obstetrical** -pregnancy- previous/current, prolapsed uterus, cystocele - **Menopause** - Symptoms/ Onset/Treatments - **Urinary:** Frequency, urgency, hematuria, incontinence - Any burning or pain on urinating? History of UTI's, calculi - **Vagina** - discharge, vaginitis risk factors (BCP, antibiotics, diabetes, altered pH) - **Sexual History** - sexually active, contraception/ type - **STI history** - self and partner(s) ## Perianal Subjective: - Complaints of rectal itchiness, burning, bleeding, throbbing - History of perianal abnormalities (haemorrhoids, rectal tumours, fissures, fistula, rectal prolapsed, rectocele) ## Objective: - **Inspect: external genitalia** - Lesions - Hernias - Urethral opening - Drainage - Swelling - Erythema - Circumcised? - **Inspect: perianal area** - Lesions - Inflammation - Rectal hemorrhoid/ fissures/ pilonidal cyst - Check urine for color, clarity, appearance, odor and volume - Catheter - **Percuss:** Costovetebral Angle Tenderness (CAT) # Neurological System ## Subjective: - Headache - Head Injury - Dizziness/Vertigo - Seizures - Tremors - Weakness - Coordination problems - Numbness/Tingling - Difficulty Swallowing/Difficulty Speaking - Significant Past History - Environmental & Occupational Hazards ## Objective: **Highest to lowest function** ### Cerebral function: - Mental status: - LOC: orientation to person, place, time - Glasgow Coma Scale - Pupils CN III, IV: See page 326-327 - Symmetry - Size - Direct/consensual response - Accommodation - Charted as PERRLA when normal response is present ### Cerebellar Function: - Balance Tests – Gait & Romberg - Coordination - Finger to nose/finger to finger/RAM/heel to shin - Motor System - Muscles of limbs only - Size - Strength - Tone - Involuntary Movements ### Sensory System (Spinothalamic): - Pain - dull/sharp - Temperature – Dermatomes only to be done if epidural/spinal anesthesia ### Reflexes: - Stretch or Deep Tendon Reflexes - Biceps, Quadriceps - Superficial Reflexes: - Plantar Reflex ### Neuro Re-Check: Used when patient showing neuro deficits as baseline and follow-up assessment - GCS - LOC - Pupillary response - Motor function - Vital signs ### Cranial Nerves: Perform tests for - CN 3-Oculomotor - CN 4- Trochlear - CN 5 - Trigeminal Nerve - CN 11 - Spinal Accessory Nerve - CN 12 – Hypoglossal Nerve # Musculoskeletal System ## Subjective: - Joints - Muscles - Bones - Functional Assessment - Self-Care Behaviours/ADL ## Objective: ### Inspection - Size & contour of joints - Skin over joints for color, swelling, masses or deformities ### Palpation: Palpate each joint for: - Temperature - Muscles - Bony articulation & area of joint capsule – note any heat, tenderness, swelling or masses ### Range of Motion of each joint: Describe the expected range - Active and passive (only to be done if limitations with active) ### Muscle Testing: - Test strength of the prime mover muscle groups for each joint, moving against resistance ### Neurovascular Checks: For ANY fracture, or cast - CSM Checks (circulation/sensation/movement) - Color - Sensation - Warmth - Movement - Pulses - Pain # Eyes, Ears, Nose, Mouth & Throat ## Subjective: - Consult Jarvis for each individual assessment ## Objective: ### Eyes - **Inspect:** Inspect external ocular structures - General - Eyebrow - Eyelid and lashes - Eyeballs - Conjunctiva and Sclera - **Inspect:** Inspect anterior eyeball structure - Cornea and lens - Iris and Pupil (pupillary light reflex done in CNS) - **Test:** - Visual acuity - Snellen Eye Chart (CN II) - Visual fields - Confrontation test - Extraocular muscle function - Cover-Uncover Test - Diagnostic Positions test (CN III, IV, VI) ### Ears - **Inspect & Palpate:** External ear - Size - Shape - Skin Condition - Tenderness - External Auditory Meatus - **Inspect:** Internal ear and structures using the otoscope - External canal - Tympanic membrane- color, integrity, position - **Test:** Hearing acuity with Whispered Voice Test (CNVIII) ### Nose - **Inspect:** External nose for symmetry, deformity & lesions - **Palpate:** Testing patency of each nostril by obstructing one nare at a time - Sinus locations for tenderness ### Mouth & Throat - **Inspect - using penlight:** - Lips - Gums - Teeth - Tongue - Buccal mucosa - Palate - Tonsils - Pharyngeal wall ### Cranial Nerves: Perform tests for - CN 2 - Optic Nerve Sensory - CN 3 - Oculomotor Nerve - CN 4 - Trochlear Nerve - CN 6 - Abducens Nerve - CN 7 - Facial Nerve - CN 8 - Acoustic (Vestibulocochlear) Nerve - CN 9 – Glossopharyngeal Nerve - CN 10 - Vagus Nerve - CN 12- Hypoglossal nerve # Head to Toe (Jarvis, 2019, p.842-846) - 60 sec/General Survey - Vital Signs including pain assessment - **Neurological system:** - Spontaneous eye opening - Verbal response - Pupils - Motor response - Muscle strength - Ptosis/facial droop - Sensation - Gag reflex/ability to swallow - **Respiratory System:** - Assess if patient is on O2 - Assess respiratory effort - Ask re: SOB - Auscultate anterior, posterior, lateral - DB&C teaching - Incentive spirometry if indicated - **Cardiovascular System:** - Auscultate rhythm at apex - Pulse deficit - Auscultate the precordium with bell and diaphragm - Assess for pretibial edema - Palpate posterior tibial and dorsalis pedis - **Integumentary System:** - Note skin color - Palpate skin temperature - Assess skin turgor and mobility - Note skin integrity - Complete Braden scale is necessary - **GI System:** - Assess abdominal contour - Auscultate bowel sounds - Palpate abdomen - Assess flatulence, BMs - Ensure diet ordered - **GU System:** - Nausea, vomiting - Voids/catheter - Assess 24-hour fluid balance - **Activity:** - Confirm activity orders - TLR assessment - Report critical findings and document - **Lateral Lung Auscultation:** - **Right Lateral Lung Auscultation:** - 3 spots on the right, ensuring the second spot is over the right middle lobe (RML) - **Left Lateral Lung Auscultation:** - 2 spots on the left, one over the left upper lobe (LUL) and one over the left lower lobe (LLL) - **Reminder:** laterally lung tissue extends from the apex of the axilla to the 7th or 8th rib.