D222 Health Assessment Script: Video Submission Guide

Grace J.
November 11, 2025November 11, 2025
BSN, D222, Western Governors University

Student Name

Western Governors University

D222 Comprehensive Health Assessment

Prof. Name

Date

Introduction

Hello, my name is ________. This document presents my comprehensive health assessment video submission, where I will perform a structured and systematic physical examination on a volunteer patient. The objective of this assessment is to demonstrate proficiency in clinical observation, measurement, communication, and physical examination techniques that align with professional nursing standards.

Introduction to the Volunteer

This section introduces my volunteer patient.

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

Once the patient’s identity was verified, I continued:
“Do I have your permission to record and conduct a full physical health assessment today?”

Upon receiving consent, the assessment commenced. The importance of patient consent and respect for confidentiality were emphasized throughout the procedure in accordance with ethical health care practice guidelines (American Nurses Association, 2023).

Part 1: Measurements and Vital Signs

Initial Assessment (Sitting Position)

At this stage, I initiated the health interview and collected baseline measurement data, including vital signs, while the patient remained seated in a comfortable and upright position. This step ensures that all physiological readings are recorded under standardized conditions to maintain accuracy and reliability.

Health Interview Questions

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

Vital Signs Assessment

Radial Pulse: The radial pulse was palpated for 30 seconds and multiplied by two. The rate, rhythm, and amplitude were normal, with a strength of +2 and a regular rhythm.
Respirations: Respiratory rate was observed for 30 seconds and multiplied by two. Breathing was even, unlabored, and without use of accessory muscles.
Blood Pressure: Measured in a seated position with feet flat and legs uncrossed. Readings were within normal limits (WNL), suggesting adequate cardiovascular function.

Skin Assessment

The patient’s skin was inspected for color, texture, and integrity. No abnormalities such as erythema, cyanosis, or jaundice were observed. Through palpation, the skin was noted to be warm, dry, and smooth, indicating proper hydration and circulation.

Hands and Nails

The hands showed no swelling or dryness, and turgor was normal, suggesting appropriate hydration. Nail inspection revealed no clubbing, thickening, or discoloration, which aligns with healthy peripheral perfusion and oxygenation.

Head and Face Assessment

The head and facial areas were examined for symmetry, tenderness, lesions, or trauma. The scalp was free from scaling and scars. The patient denied pain or discomfort.

Cranial Nerve VII (Facial Nerve) Examination

The patient was asked to raise the eyebrows, close the eyes tightly, smile, frown, and puff the cheeks. Facial symmetry and muscle tone were equal bilaterally, indicating that Cranial Nerve VII was intact.

Eyes

The eyes were examined for alignment and symmetry. Eyelids showed no 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, measuring approximately 3 mm at rest and constricting appropriately with light.

Cranial Nerve II and Peripheral Vision Test

The confrontation test confirmed intact peripheral vision, indicating proper functioning of Cranial Nerve II (Optic Nerve).

Extraocular Muscles (Cranial Nerves III, IV, VI)

Using the six cardinal fields of gaze, ocular movement was smooth and coordinated. There was no evidence of nystagmus or strabismus.

Corneal Light Reflex

A symmetric reflection of light was seen in both eyes, confirming proper ocular alignment.

Ears

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.

Nose

The nasal structure was straight and symmetric. No discharge or inflammation was present, and both nostrils were patent. The patient denied any history of epistaxis.

Mouth and Throat

Oral Health Questions

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 Examination

Lips and mucous membranes were moist and pink, with no lesions. The gums and tongue appeared healthy with good dentition. The patient denied gum bleeding.

Cranial Nerves IX and X (Glossopharyngeal and Vagus)

The uvula elevated midline when the patient said “ah,” and the gag reflex was intact, indicating normal cranial nerve function.

Neck Assessment

The neck was symmetric with no masses or lymphadenopathy. The trachea was midline, and carotid pulses were palpable and free of bruits. Cranial Nerve XI (Accessory Nerve) was tested through head resistance and shoulder shrug, both of which were strong and equal bilaterally.

Part 3: Chest and Lungs

Posterior Thoracic Assessment

The thoracic cage was symmetric with normal expansion and no tenderness. Lung fields were clear bilaterally with no adventitious sounds detected.

Anterior Thoracic Assessment

Respiratory movement was even with no accessory muscle use. Breath sounds were clear throughout all lobes.

Heart Assessment

The apical pulse was auscultated at the fifth intercostal space, midclavicular line, for one full minute. S1 and S2 heart sounds were present, distinct, and regular with no murmurs or extra sounds. All five cardiac landmarks were assessed with normal findings.

Upper Extremities

Both arms displayed full range of motion and equal strength. Pulses were +2 bilaterally, and capillary refill was less than two seconds, signifying effective peripheral circulation.

Part 4: Jugular Vein and Abdomen

Jugular Vein

No jugular venous distention was observed when the patient was positioned at a 45-degree angle.

Abdominal Assessment

Method	Findings
Inspection	Abdomen slightly rounded, symmetrical, no bulges
Auscultation	Normoactive bowel sounds in all quadrants
Palpation	Soft, non-tender, no masses detected
Percussion	Tympanic sounds noted, no dullness

Lower Extremities

Both legs appeared symmetrical with normal color and warmth. No edema or ulcers were observed. Peripheral pulses (femoral, popliteal, posterior tibial, and dorsalis pedis) were 2+ bilaterally, and capillary refill was under two seconds.

Part 5: Neuromuscular System

Deep Tendon Reflexes

Reflexes were brisk and symmetrical at the biceps, triceps, brachioradialis, patellar, and Achilles tendons, indicating 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 performed heel-to-toe walking, tiptoe walking, and heel walking without imbalance, indicating coordinated motor function.

Patient Education and Recommendations

1. Sleep Hygiene

The patient reported an average of six hours of sleep nightly. Education was provided on the importance of achieving 7–8 hours of quality sleep to promote cardiovascular health, cognitive performance, emotional regulation, and immune function (Centers for Disease Control and Prevention [CDC], 2023).

2. Physical Activity

The patient was encouraged to increase physical activity to meet the World Health Organization (WHO, 2023) recommendation of at least 150 minutes of moderate-intensity aerobic exercise per week, supplemented by two days of strength training. Examples included brisk walking, cycling, and swimming to enhance cardiovascular endurance and musculoskeletal strength.

Follow-up with a primary healthcare provider was advised for continued health monitoring and management of any emerging symptoms.

Conclusion

This assessment concluded successfully with all findings within normal limits. The patient tolerated the examination well, and no abnormal results were observed. The interaction emphasized the importance of systematic observation, communication, and patient-centered care in holistic nursing assessment.

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