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Head-to-Toe Assessment Script
Head to toe
Terms in this set (23)
My name is Stacey and I'm a student nurse. I'm going to be conducting your head-to-toe examination. Do you have any questions for me today?
Okay, let's get started then. Can you state your full name for me? And what is your data of birth? (Go wash hands)
I'm going to take your vital signs now. Let me first estimate your blood pressure and we'll come back to that. Your pulse is ______ and your respirations are _______/minute. Your temperature is ___________. Now I'm going to take blood pressure. Your blood pressure is ________________
I'm going to be observing the patient's skin throughout the exam. May I remove your glasses? Your facial features look symmetrical. (Put on gloves)The scalp does not have any lesions or pest inhabitants. Remove gloves and gel hands.
I'm going to feeling for any lumps or tenderness in your face. Does this hurt? Now I'm going to check your sinuses. Does this hurt?(press up under eyebrows) How about this (press up under zygomatic). Let's check your to see that your jaw is working smoothly (press at TMJ). Good, I don't feel any clicking or crepitus and your jaw opens smoothly.
Now I'm going to test facial sensation with this cotton ball. I'm going to have you shut your eyes and tell me "now" when you feel the cotton on your skin like this (brush cotton on pts arm). Can you shut your eyes please? (brush cotton on forehead, cheek and mandible). Good, you can open your eyes now. (palpate temporalis) Can you clench your jaw? Good. (palpate masseter) Clench again. Good. Your facial sensations are intact and your have good jaw strength so I know that your 5th cranial nerve is intact.
Now we're going to test your facial nerve. Can you make a frown? a smile? show your teeth? and now puff out the cheeks. Good. The nerve is intact.
I'm going to take a look your eyes now. (look for any redness or assymetry in eyes). Can you shut your eyes for a moment. Good, the eyes, lids and lashes are all healthy.
Now I'm going to test eye muscles. Can you follow my finger as I pass through the six positions? (Hold at extreme left and right) Ok, and now just look at a point behind my head as I shine this light. Good, your eye muscles are healthy and I did not see any sign of lazy eye. The cranial nerves 3, 4 and 6 controlling eye moments are all intact.
Let's take a look at the cornea(light side to front). Good. Looks smooth and round with no scratches. (Pull down bottom lid) the lining of the eyelid is pink and healthy. Iris and pupil are round and symmetrical.
I'm going to check your pupil reaction now. Can I have you hold your hand up like this? (direct and consensual test) Good. The pupillary responses are intact. Now let me have you focus your gaze on a point on the wall behind me. Now look at my finger. Good. Now look at my finger. Good, the pupils constricted and converged, which is normal. Your optic and occulomotor nerves are intact.
Now we're going to check your hearing. What I'm going to do is whisper several words behind you. Please repeat the words you hear. Can I have you block your right ear like this (demonstrate) and move the finger around slightly so it makes noise? Good. (Busstop, football, raindrop) Now switch ears. ( keyboard, makeup, notebook. ) Good, your auditory nerve is intact.
I'm going to touch your ears now to feel for any lumps or tenderness. Please let me know if you feel any discomfort. (Pinna, tragus) Good. I don't see redness, drainage or swelling.
I'm going to take a look at your nasal cavity now. (put on gloves) Can you tip your head back for me? (lift tip of nose, shine light in each nare) I do notice that your septum is deviated but I don't see any swelling. Your nasal cavities look healthy. (take off gloves and gel hands)
Let's take a look at your mouth and throat. (use tongue blade and light) Your gums look pink and healthy, teeth are all present ,inside of the mouth (buccal mucosa) is pink and smooth. I don't see any lesions on top of tongue, soft and hard palates, tonsils or pharnyx. The mouth looks very healthy.
Can I have you stick out your tongue? The tongue is centered and you are able to stick it out. That means your hypoglossal nerve is intact. Can you stick it out again and say "AH"? Good, the soft palate and uvula rise when you do that, telling me your 9th and 10th cranial nerves are functioning.
I'm going to inspect your neck now. Let me know if you feel any tenderness where I touch. The windpipe( trachea) is centered (@ suprasternal notch) and moveable. I don't see or feel any swelling.
Next I'm going to palpate your lymph nodes. Tell me if you feel any pain or tenderness as i do this. Can I have you tilt your head to the right, now the left. now shrug your shoulders. Good. I did not feel any of your lymph nodes and they are not tender which means they are not swollen, which would be a sign of infection.
Can I have you shrug your shoulders against my hand? now turn your head against the hand, they other side. Good your shoulder and neck muscles are strong and your spinal accessory nerve is intact.
can you hold your hands out for me. Let me know if you feel any pain or tenderness (palpate hands and nails, pinch skin) the hands are warm and dry and i don't feel any lumps, the nails are smooth and non--tender. the skin has good turgor which means it has good elasticity and you are well hydrated. (palpate arms and shoulders) arms and shoulders have good muscle tone and appear equal. There are some moles visible, but none that are concerning.
I'm going to compare your pulses now. can you hold out your hands for me, palm up? good, both pulses are present and equal bilaterally. pulse strength is normal. (capillary refill) the color comes back quickly when i pinch your nail bed. you have good circulation in the arms and hands.
Can you try to raise your arm against my resistance? Good, now try to lower the arms against my resistance. now make a fist with both hands. You have good muscle strength in the upper arms and good grip strength. both sides appear equal.
I want to observe the range of motion in your shoulders now. With your palms down, can you raise your arms out to the sides? now face palms up and raise them all the way up. Now touch the palms and place them behind your neck. now extend the arms out again and try to touch your shoulder blades behind your back. Good. You have a full range of motion in both arms.
Can I have you hold the gown up for a moment. I'm checking to see the proportions of your torso. (use hands to measure) The AP:lateral ratio is 1:2, which is normal. I do not see any signs of lesions or abnormalities. There are some moles present but none that are concerning.
I'm going to go around behind you to take a look at your back. Let me know if you feel any discomfort during breathing. Can you take several deep breaths for me? In, then out. again. Keep breathing. Now I'm going to check your chest expansion. You're going to feel my hands on your back. Can you take another deep breath now? Good, chest expansion is full, and symetrical.
So now I'm going to palpate the back and sides for any lumps or abnormalities. Are you noting any pain or tenderness? I don't feel any lumps or masses. There are some nevi, but nothing of concern. The skin is warm and dry.
The spinal column is straight with the exception of a slight lateral lumbar curve. We will probably want to refer you out for scoliosis screening. Other than that, the spine is straight and non tender
I'm going to take a listen to your lung sounds now. (alcohol swab the stethoscope). When you feel the stethoscope on your skin, please take a deep breath in and out with your mouth open. if you feel dizzy please let me know. (start at C7 and move down, side to side. make sure to hit RML)
Normal breath sounds are present and clear in all fields. I don't hear any crackles or wheezes, no adventitious sounds to indicate lung disease.
I'm going to listen to the lungs from the front now. As you feel the scope on your skin, please take a deep breath in and out and let me know if you feel dizzy.
Lungs sound clear and normal breath sounds are present in all lung fields. There are no crackles or wheezes. Your lungs sound very healthy
I'm going to have you lie back on the table now so that i can better assess your heart. let's put this pillow under your legs. I'm noting that your clavicles are not equal bilaterally. There are some moles present on the skin but nothing alarming. breathing is normal and symetrical. Let me know if you feel any pain or tenderness as I check for lumps. I do not note any masses. I cannot see your apical pulse, but this is normal. I can feel a strong apical pulse at the 5th left intercostal. I am not noting abnormal vibrations.
I'm going to listen to your heart sounds now. Don't worry if i listen at a particular spot for a while - it's a normal part of the exam and doesn't mean anything is wrong. (clean off diaphragm and bell) All your heart sounds are present and you have a regular rhythm. I'm hearing S2 at the base and S1 at the apex and I do not hear any murmurs. Your heart sounds healthy.
I'm going to lift the gown up and push your pants down a bit to examine your abdomen now. The contour is flat, i don't see any concerning moles. No scars present. There are no visible bulges. i can see a bit of a pulse which is good.
Now i'm going to listen to your bowel sounds. Do you have any pain or tenderness anywhere in your stomach? (clean off diaphragm) Bowel sounds are present and normal in all 4 quadrants.
I'm going to palpate your stomach now. Let me have you bring your knees up to make this a little more comfortable. I do not feel any lumps or abnormalities. This is good.
Let's move on to the legs now. let me know if you feel any pain or tenderness. I'm noting some leg muscle atrophy on the side with the injury. This is normal considering the condition. The skin is pink, hair is present bilaterally and equal. (feel temp with back of hands both legs) the skin is warm and dry. (palpate legs and feet) i am not noting any masses or lumps.
I'm going to check for pulses in your feet. The posterior tibial pulse present bilaterally and normal force. The dorsalis pedis pulse is present on both sides and normal. (press skin on shin) I am not seeing any swelling. (check cap refill on toenails) The color comes back to your skin quickly when pressed. This means you have good circulation to the legs and feet.
We're going to check your hip and knee range of motion. let me know if you feel pain at any time. Can you pull your right knee up toward your chest? now the left. good flexion at knee is present. I'm going to hold your hip down to stabilize it. can you move the leg opposite the one im holding out in an arc like you are going to make a snow angel? Good abduction is present. now move it inward, crossing over the other leg. Good adduction is present. now bend the knee and place your foot flat on the table. Let your knee drop out to your side. Good external rotation is present. now swing the knee back in and try to cross to the opposite side. Good internal rotation is present. Now let's put that leg flat on the table and repeat this sequence with the left leg. Full range of motion is present.
Let me have you come up to seated and table your legs off the table. Reflexes
we're going to test muscle strength now. can you extend your leg for me by kicking out? now bring it back in. now point your toes to the ground, and bring them back up towards you. Other side. full ROM of lower legs is present.
Okay. I'm going to have you come to standing now. Can you try to touch your toes? Now bend backward (steady pt at hips) now rotate without moving your hips to the right, now the left. now lean your upper body sideways to the right, now the left. The spine has a full ROM
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