nurs 210 sample_head_to_toe_assessment_script 22.pdf

FINAL HEAD TO TOE SCRIPT

VITAL SIGNS & BEGINNING

Sanitize hands and put on gloves.

Hi, my name is ____________. I am a Liberty University Nursing student, and I will

be performing a head to toe assessment this morning. Can you please state your

name and date of birth?

Thank you. I completed hand hygiene by sanitizing my hands and putting on gloves

and have provided for patient privacy.

We are going to start by taking your oral temperature. Have you had anything to

drink in the last 20 minutes?

Your HR is ___ regular and strong. This is within the normal limits of 60-100 bpm.

Your respirations are ___ and are easy, unlabored and even. This is within the

normal limits of 12-20 respirations per minute.

Next I will be assessing for your auscultatory gap. (place BP cu on the patient, feel

for cease of pulse and continue to pump 20 beyond)

The palpable BP was ____, no auscultatory gap was noted, and I will inflate the cu

an additional 20 mmHg above this when I measure the BP.

Your BP was ____ over _____ which is within normal limits as the normal numbers

are 120/80.

PART ONE

(check skin turgor on BOTH hands AND BOTH feet) I will now assess the skin turgor.

The skin is resilient and the patient appears to be well-hydrated.

I will now examine for lesions. (remember each of the three, examine thoroughly)

The patient has primary lesions including macules scattered throughout the arms

and legs, which are distributed evenly and none exceed 6mm in size. No secondary

or vascular lesions are noted such as purpura or bruising.

The hair distribution on the lower extremities is evenly distributed with no evidence

of varicosities or edema.

***upper AND lower extremities***

Nails

firm and there is no separation noted. The capillary refill is normal and is all under 3

seconds.

We will now move on to the head. The patient’s head is normocephalic, appearing

symmetrical and atraumatic. The face is symmetrical and is also normal in shape

and size.

I will now assess the scalp. (palpate and test for mobility) The scalp is mobile and

appears to be symmetrical with no depressions, steps, bumps or lesions noted.

Next, I will assess your hair. (begin looking for infestation signs) The patient’s hair is

brown and thick in texture. It is evenly distributed on the scalp. It is not oily and

appears to be brushed.

Palpate paranasal sinuses. I will now assess the frontal and maxillary sinuses. Did

you feel any tenderness? No tenderness was noted.

Please clench your jaw. Now open and close. Jut it forward and back. Now side to

side. Jaw strength, clench and lateral movement is normal.

We are now going to do facial gymnastics to test the function of cranial nerve 7 the

facial nerve. Please smile without showing your teeth. Frown. Close your eyes and

raise your eyebrows. Now try and keep your eyes closed as I try and open them.

Smile with teeth. Pu out your cheeks. Purse lips. Thank you. Cranial nerve 7

appears to be functioning properly.

PART TWO

Eyes

Now moving on to the eyes.

with no evidence of clouding and the iris is blue in color.

I will now feel the lacrimal sac and gland for any edema or tenderness. Did you feel

any tenderness with that? No tenderness noted.

PERRLA (swoop pen light)

The pupils are round, equal and reactive, the response to light was direct and

consensual constricting from a size of __ cm to __ cm.

We will now assess for accommodation (focus on pen light close and far).

Accommodation is normal with normal convergence and constriction.

Visual Acuity

We will now assess visual acuity involving cranial nerve II the optic nerve.

cover your right eye. Please say now when you see my fingers. (North, South, East,

West and Temporal) The patient’s visual fields are normal.

We will now assess the function of cranial nerve III the oculomotor nerve, CN IV the

trochlear, and CN VI the abducens.

I will now assess the 6 cardinal fields of gaze. Please keep your head still and focus

your eyes on my pen as it moves. The patient’s test is normal.

Now we will assess the corneal light reflex. I’m going to have you look over my

shoulder at the cabinet. (shine on bridge of nose, make sure light reflects on bridge

of nose) The corneal light reflex is symmetrical, no evidence of strabismus.

The cover/uncover test would only be done if the patient had failed the corneal light

reflex but I will now demonstrate how it would be done.

Please cover one eye. Look at my pen. Now uncover. The patient’s test is normal.

I will now use an otoscope to examine the ear canal of the right ear. Typically this

would be done on both ears. I see the tympanic membrane which was pearly gray

and the left ear would be at 7 o’clock. I am noting the pars tensa and pars flaccida

as well as the umbo and malleus. All of these structures are in the correct positions

and locations.

We will now assess cranial nerve 8, the acoustic nerve. We will begin with a whisper

test. (BOTH EARS) The patient’s test is normal.

Now we will do a Weber test, please let me know if you hear this equally in both

ears. The patient’s test is normal.

Now the Rinne test, let me know when you stop hearing the sound. The air to bone

conduction ratio was 2:1 which is normal. We would do this test on both ears.

PART THREE

Upon inspection, the nose is of normal shape and size, showing symmetry.

(Use pen light) There is no septum deviation, the mucosa are in good condition and

the turbinates are noted towards the back of the nares. .

Close your eyes, Cover one nostril breathe in, what do you smell? (BOTH NARES)

The patient’s cranial nerve 1, the olfactory nerve, is intact. Both nares are patent

spacing. The gums appear pink in color with no signs of bleeding.

The buccal cavity and sublingual area are in good condition with no calculi or

masses.

The tongue is in good condition being pink in color and normal in size. (Say ah) The

patient’s uvula is midline and remains midline with the rise of soft palate.

The anterior & posterior tonsillar pillars are in the correct position and good

condition, the tonsils are grade 2, and the posterior pharynx is in good condition

with no edema noted.

We will now continue to assess cranial nerve 9 the glossopharyngeal nerve and

cranial nerve 10 the vagus nerve. Can you swallow—thank you. Your speech has

been normal throughout the assessment. Normally we would assess your gag reflex

but we will defer that today. Cranial nerves 9 and 10 are intact.

We will now assess cranial nerve XII, the hypoglossal nerve. Stick your tongue out,

move it side to side. The patient’s test is normal with no evidence of midline

deviation or twitching. Cranial nerve XII is intact.

your shoulders. Now press against my hands (both sides). Cranial nerve XI is

functioning properly and the sternocleidomastoid muscle has normal strength. .

(Inspect trachea) The trachea appears to be midline and symmetrical with no signs

of protrusions. We will palpate this in just a minute.

submandibular.

Palpate anterior cervical chains, posterior cervical chains, & deep cervical chains.

None of the lymph nodes had an erythema, edema or tenderness.

Inspect carotid arteries _____ palpate, auscultate (***bell). No bruits noted.

I will now assess the thyroid. (Palpate, walk down the trachea) Please tilt your head

to one side. Now the other. The thyroid appears to be symmetrical of normal size

and shape with no sign of edema or nodular aspects. Is this tender? No tenderness

noted. Then auscultate (***bell or diaphragm?).

PART FOUR

***Don’t auscultate or percuss through fabric***

Lungs

Upon initial inspection, the skin on the thorax anteriorly and posteriorly is consistent

with the rest of the body in color. The chest is symmetrical bilaterally being normal

in shape with anterior to posterior diameter being half that of the transverse.