D222 Health Assessment Script: Video Submission Guide

D222 Health Assessment Script: Video Submission Guide

Student Name

Western Governors University 

D222 Comprehensive Health Assessment

Prof. Name

Date

Introduction

My name is ________. This document outlines my comprehensive health assessment video submission, which demonstrates a complete, organized, and methodical physical examination performed on a volunteer participant. The purpose of this assessment is to exhibit competence in therapeutic communication, clinical observation, accurate measurement, and hands-on examination skills consistent with professional nursing practice standards. Emphasis is placed on patient safety, ethical conduct, and evidence-based assessment techniques throughout the process.

Introduction to the Volunteer

This section presents the volunteer who participated in the health assessment.

Verification and Consent Process

To ensure patient safety and confidentiality, the assessment began with identity verification and informed consent. The following questions were asked exactly as part of the assessment dialogue:

“Could you please state your full name and date of birth for verification purposes?”

After verification, informed consent was obtained by asking:

“Do I have your permission to record and conduct a full physical health assessment today?”

Once verbal consent was granted, the assessment proceeded. Respect for patient autonomy, confidentiality, and ethical standards was maintained in alignment with professional nursing guidelines (American Nurses Association [ANA], 2023).

Part 1: Measurements and Vital Signs

Initial Assessment (Seated Position)

The assessment began with the patient seated upright in a comfortable position. This posture ensured accurate baseline measurements and standardized physiological readings. A brief health interview was conducted simultaneously to gather subjective data relevant to the patient’s overall health status.

Health Interview Questions and Responses

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	____ (within normal range)
Do you have any pain?	No pain reported (0/10)
Are you physically active?	No
How many hours do you sleep per night?	Approximately 6 hours
Do you attend annual physical examinations?	Yes

Vital Signs Assessment

The radial pulse was palpated for 30 seconds and multiplied by two. The pulse rate was regular, with normal rhythm and an amplitude of +2, indicating adequate cardiac output. Respiratory rate was observed discreetly for 30 seconds and doubled, revealing even, unlabored breathing without accessory muscle use. Blood pressure was obtained with the patient seated, feet flat on the floor, and legs uncrossed. The reading fell within normal limits, suggesting effective cardiovascular regulation.

Skin, Hands, and Nails Assessment

Inspection of the skin revealed uniform color and intact integrity with no evidence of erythema, cyanosis, or jaundice. Palpation indicated the skin was warm, dry, and smooth, consistent with proper hydration and perfusion. The hands demonstrated normal turgor without swelling or dryness. Nail beds were pink with no clubbing, thickening, or discoloration, reflecting adequate peripheral oxygenation.

Part 2: Head, Neck, and Sensory Systems

Head and Facial Assessment

The head and face were symmetrical and free from lesions, masses, or tenderness. The scalp was intact without scaling or scarring, and the patient denied discomfort.

Cranial Nerve VII (Facial Nerve)

The patient was instructed to raise the eyebrows, close the eyes tightly, smile, frown, and puff out the cheeks. Facial movements were symmetric and strong bilaterally, confirming intact facial nerve function.

Eye Assessment

The eyes were inspected for symmetry, alignment, and external abnormalities. Eyelids showed no ptosis or edema. The sclera appeared white, and the conjunctivae were pink and moist.

Pupillary Response (PERRLA)

Pupils were equal, round, and reactive to light and accommodation. They measured approximately 3 mm at rest and constricted appropriately with light exposure.

Cranial Nerve II and Extraocular Movements

Peripheral vision was assessed using the confrontation test, with normal results indicating intact optic nerve function. Extraocular movements were evaluated through the six cardinal fields of gaze. Eye movements were smooth and coordinated, with no evidence of nystagmus or strabismus, confirming proper function of cranial nerves III, IV, and VI. The corneal light reflex was symmetrical bilaterally.

Ear Assessment

Both ears were symmetrical and free of lesions, discharge, or tenderness. The patient denied hearing loss, tinnitus, or vertigo. External auditory structures appeared healthy.

Nose Assessment

The nasal septum was midline, and the nose was symmetric without inflammation or discharge. Both nares were patent, and the patient denied any history of nosebleeds.

Mouth and Throat

Oral Health Questions and Responses

Question	Response
When was your last dental visit?	Recent dental check-up
How often do you brush and floss your teeth?	Brushes twice daily and flosses regularly

Oral and Cranial Nerve Examination

The lips and oral mucosa were moist and pink with no lesions. Gums were healthy, and dentition was intact. The tongue appeared midline without abnormalities. When the patient said “ah,” the uvula elevated midline, and the gag reflex was present, confirming intact cranial nerves IX and X.

Neck Assessment

The neck was symmetric with full range of motion. No masses or lymphadenopathy were palpated. The trachea was midline, and carotid pulses were palpable without bruits. Cranial nerve XI was assessed through shoulder shrug and head rotation against resistance, demonstrating equal strength bilaterally.

Part 3: Chest, Lungs, and Cardiovascular System

Posterior and Anterior Thoracic Assessment

The thoracic cage was symmetric with normal expansion. Lung auscultation revealed clear breath sounds bilaterally with no adventitious sounds. Anteriorly, respiratory movements were even, and no accessory muscle use was observed.

Cardiac Assessment

The apical pulse was auscultated for one full minute at the fifth intercostal space along the midclavicular line. Heart sounds S1 and S2 were clearly audible and regular. No murmurs, rubs, or gallops were detected. All five cardiac landmarks were assessed with normal findings.

Upper Extremities

Both upper extremities demonstrated full range of motion and equal muscle strength. Peripheral pulses were +2 bilaterally, and capillary refill was less than two seconds, indicating effective circulation.

Part 4: Jugular Vein, Abdomen, and Lower Extremities

Jugular Vein Assessment

With the patient positioned at a 45-degree angle, no jugular venous distention was observed, suggesting normal central venous pressure.

Abdominal Assessment Findings

Method	Findings
Inspection	Abdomen slightly rounded and symmetrical
Auscultation	Normoactive bowel sounds in all quadrants
Palpation	Soft, non-tender, no masses
Percussion	Predominantly tympanic sounds

Lower Extremities

The lower extremities were symmetrical with normal color and temperature. No edema, lesions, or ulcers were present. Peripheral pulses—including femoral, popliteal, posterior tibial, and dorsalis pedis—were +2 bilaterally. Capillary refill remained under two seconds.

Part 5: Neuromuscular Assessment

Deep Tendon Reflexes

Deep tendon reflexes were assessed at the biceps, triceps, brachioradialis, patellar, and Achilles tendons. Reflexes were brisk and symmetrical, indicating intact neurological pathways.

Sensory, Coordination, and Spine Assessment

The patient accurately identified sharp and dull sensations on all extremities, confirming intact peripheral sensation. The spine was midline with normal curvature and full range of motion. Coordination tests—including heel-to-toe walking, heel walking, and tiptoe walking—were performed without loss of balance.

Patient Education and Health Promotion

Sleep Hygiene

The patient reported an average of six hours of sleep per night. Education was provided regarding the benefits of obtaining seven to eight hours of quality sleep, including improved cardiovascular health, immune function, cognitive performance, and emotional well-being (Centers for Disease Control and Prevention [CDC], 2023).

Physical Activity Recommendations

The patient was encouraged to gradually increase physical activity in accordance with World Health Organization (WHO, 2023) guidelines, which recommend at least 150 minutes of moderate-intensity aerobic activity per week along with muscle-strengthening activities on two or more days. Suggested activities included brisk walking, swimming, and cycling.

Follow-up with a primary healthcare provider was recommended to support ongoing health maintenance and early identification of potential concerns.

Conclusion

The comprehensive health assessment was completed successfully, with all findings within normal limits. The patient tolerated the examination without difficulty. This assessment highlights the value of systematic examination, effective communication, and patient-centered care in delivering holistic nursing practice.

References

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

D222 Health Assessment Script: Video Submission Guide

World Health Organization. (2023). Physical activity fact sheet. https://www.who.int/news-room/fact-sheets/detail/physical-activity