HESI HEALTH ASSESSMENT FORTIS
Prioritize-the-nursing-actions---ans-✔✔ABC-rule:
Airway
Breathing
Circulation
two-point-discrimination:-Fingers---ans-✔✔2-3-mm
two-point-discrimination:-Palm---ans-✔✔10-mm
two-point-discrimination:-Forearm---ans-✔✔35-mm
Two-point-discrimination:-Upper-arm---ans-✔✔39
Cranial-Nerves---ans-✔✔12-pairs-of-nerves-that-carry-messages-to-and-from-the-brain
Nerve-I---ans-✔✔Olfactory
Nerve-II---ans-✔✔Optic
Nerve-III---ans-✔✔Oculomotor
Nerve-IV---ans-✔✔Trochlear
Nerve-V---ans-✔✔Trigeminal
Nerve-VI---ans-✔✔Abducens
Nerve-VII---ans-✔✔Facial
Nerve-VIII---ans-✔✔Acoustic
Nerve-IX---ans-✔✔Glossopharyngeal
Nerve-X---ans-✔✔Vagus
Nerve-XI---ans-✔✔spinal-accessory
, Nerve-XII---ans-✔✔Hypoglossal
Hips-ROM-Osteoarthritis---ans-✔✔Pain-increases-at-night,-movement-increases-pain
Reasons-for-enlarged-spleen---ans-✔✔traumatic-injury
acute-infection-(mono)
referred-chest-pain,-back,-mid/upper-R-section-of-abd.
Hemorrhoids---ans-✔✔painless,-flabby-pa-pules,-are-cause-by-varicose-veins.-
Thrombosed,-contains-clotted-blood-and-becomes-painful,-swollen,-shiny-blue-mass-that-
itches-and-bleeds-with-deification.-Occur-with-straining-stool,-chronic-constipation,-
pregnancy,-obesity,-chronic-liver-disease,-low-fiber-diet.
ascites-assessment---ans-✔✔pathologic-increase-in-fluid-in-peritoneal-cavity--percuss-for-
dullness-and-resonance,-shifting-dullness,-fluid-wave
breast-exam---ans-✔✔early-detection-is-important.-Every-woman-should-preform-exam-
monthly,-as-soon-as-menstrual-bleeding-has-ceased-or-if-postmenopausal-same-date-
every-month.
S1---ans-✔✔the-first-heart-sound,-heard-when-the-atrioventricular-(mitral-and-tricuspid)-
valves-close,-beginning-of-systole,-loudest-at-APEX
S2---ans-✔✔second-heart-sound,heard-when-the-semilunar-valves-close,-signals-the-end-
of-systole,-loudest-at-the-BASE
chronic-ear-infection-inspection---ans-✔✔use-an-otoscope,-for-adults-pull-up-and-back,-for-
children-pull-down.-Eardrum-is-yellow-amber-color,-scarring-and-denting-may-be-present.
Cardiovascular---ans-✔✔palpate-cold-feet,-check-pulses-in-both-feet.-May-indicate-
arterial-deficiency-or-oxygen-deficit.-deep-muscle-pain-in-calf,-lower-leg-or-foot;-
intermittent-claudication-feels-like-cramps,-numbness,-and-tingling.
Chronic-ear-infection-inspection---ans-✔✔inspect-with-otoscope.-Pull-up-and-back-for-
adults,-down-for-children.-Eardrum-is-yellow-amber-color,-scarring-may-be-present
Seizure-documentation---ans-✔✔*Course-and-duration-when-a-seizure-starts,-do-you-
have-any-warning-signs?-What-type-of-sign?
*Motor-activity-Where-in-your-body-doe-the-seizures-begin?-Do-they-travel-through-your-
body?-On-one-side-or-both?-Does-your-muscle-tone-seem-tense-or-limp
Any-associated-sign-color-change-in-face-or-lips,-loss-of-consciousness-(for-how-long),-
automatism,-incontinence
Prioritize-the-nursing-actions---ans-✔✔ABC-rule:
Airway
Breathing
Circulation
two-point-discrimination:-Fingers---ans-✔✔2-3-mm
two-point-discrimination:-Palm---ans-✔✔10-mm
two-point-discrimination:-Forearm---ans-✔✔35-mm
Two-point-discrimination:-Upper-arm---ans-✔✔39
Cranial-Nerves---ans-✔✔12-pairs-of-nerves-that-carry-messages-to-and-from-the-brain
Nerve-I---ans-✔✔Olfactory
Nerve-II---ans-✔✔Optic
Nerve-III---ans-✔✔Oculomotor
Nerve-IV---ans-✔✔Trochlear
Nerve-V---ans-✔✔Trigeminal
Nerve-VI---ans-✔✔Abducens
Nerve-VII---ans-✔✔Facial
Nerve-VIII---ans-✔✔Acoustic
Nerve-IX---ans-✔✔Glossopharyngeal
Nerve-X---ans-✔✔Vagus
Nerve-XI---ans-✔✔spinal-accessory
, Nerve-XII---ans-✔✔Hypoglossal
Hips-ROM-Osteoarthritis---ans-✔✔Pain-increases-at-night,-movement-increases-pain
Reasons-for-enlarged-spleen---ans-✔✔traumatic-injury
acute-infection-(mono)
referred-chest-pain,-back,-mid/upper-R-section-of-abd.
Hemorrhoids---ans-✔✔painless,-flabby-pa-pules,-are-cause-by-varicose-veins.-
Thrombosed,-contains-clotted-blood-and-becomes-painful,-swollen,-shiny-blue-mass-that-
itches-and-bleeds-with-deification.-Occur-with-straining-stool,-chronic-constipation,-
pregnancy,-obesity,-chronic-liver-disease,-low-fiber-diet.
ascites-assessment---ans-✔✔pathologic-increase-in-fluid-in-peritoneal-cavity--percuss-for-
dullness-and-resonance,-shifting-dullness,-fluid-wave
breast-exam---ans-✔✔early-detection-is-important.-Every-woman-should-preform-exam-
monthly,-as-soon-as-menstrual-bleeding-has-ceased-or-if-postmenopausal-same-date-
every-month.
S1---ans-✔✔the-first-heart-sound,-heard-when-the-atrioventricular-(mitral-and-tricuspid)-
valves-close,-beginning-of-systole,-loudest-at-APEX
S2---ans-✔✔second-heart-sound,heard-when-the-semilunar-valves-close,-signals-the-end-
of-systole,-loudest-at-the-BASE
chronic-ear-infection-inspection---ans-✔✔use-an-otoscope,-for-adults-pull-up-and-back,-for-
children-pull-down.-Eardrum-is-yellow-amber-color,-scarring-and-denting-may-be-present.
Cardiovascular---ans-✔✔palpate-cold-feet,-check-pulses-in-both-feet.-May-indicate-
arterial-deficiency-or-oxygen-deficit.-deep-muscle-pain-in-calf,-lower-leg-or-foot;-
intermittent-claudication-feels-like-cramps,-numbness,-and-tingling.
Chronic-ear-infection-inspection---ans-✔✔inspect-with-otoscope.-Pull-up-and-back-for-
adults,-down-for-children.-Eardrum-is-yellow-amber-color,-scarring-may-be-present
Seizure-documentation---ans-✔✔*Course-and-duration-when-a-seizure-starts,-do-you-
have-any-warning-signs?-What-type-of-sign?
*Motor-activity-Where-in-your-body-doe-the-seizures-begin?-Do-they-travel-through-your-
body?-On-one-side-or-both?-Does-your-muscle-tone-seem-tense-or-limp
Any-associated-sign-color-change-in-face-or-lips,-loss-of-consciousness-(for-how-long),-
automatism,-incontinence
