Uploaded by kimtumm

head to toe script

Hello, my name is _____ and I’m going to be your student nurse today.
Can I see your wristband? Can you tell me your full name and date of birth? Do you know where you are? Why are
you here? What year is it?
Patient is alert and oriented times four. She speaks English and speech is clear and comprehensible. Patient is
able to hear and follow commands.
Today I will be getting a complete health history, doing a total body assessment, and taking and recording your vital
signs. Is that ok?
“At this time, I will obtain, record, and document vital signs and obtain and document a complete health history.”
Patient appears to be stated age. She is sitting upright and straight with arms resting comfortably in lap. Head is
straight and upright and is normocephalic. Patient is calm and cooperative. She has normal body habitus and is well
groomed, appropriately dressed, and there is no odor noted. Skin appears warm and dry without any obvious lesions
or deformities noted. Tattoos noted
“If at any time during this assessment you have pain or tenderness, please let me know.”
Now I am going to test the cranial nerves.
Can you close your eyes and cover one nostril? Now can you tell me what you smell? Keep your eyes closed and
cover the other nostril. What do you smell? Cranial nerve one, olfactory nerve is intact.
I am going to shine this light in your eyes. Just look straight ahead.
(Assess reaction to light and pupil size, accommodation, and consensual reaction)
Look at my penlight, now look at my ear, back to my penlight, and back to my ear. Pupils are equal, round, reactive
to light, they accommodate and are consensual and constrict from ___ to ___ with the insertion of light.
Now just follow my penlight without moving your head. (Assess the 6 cardinal fields of gaze) Cranial nerve three,
oculomotor, cranial nerve four, trochlear, and cranial nerve six, abducens nerve is intact.
Do you wear glasses? (If yes, have them put them on) Can you cover one eye and read the smallest line possible.
Can you cover the other eye and read the smallest line possible, but read it backwards this time? (Tell patient their
acuity results) You have _______ vision. Cranial nerve two, optic nerve is intact.
(Move fingers into peripheral vision) Tell me when you can see my fingers. Peripheral vision is intact
Now close your eyes and tell me is what you feel is soft or sharp.
(Use Q-Tip to test the trigeminal nerve on each side of the face alternating the soft and sharp end). Cranial nerve
five, trigeminal nerve is intact,
Can your puff out your cheeks, smile, show your teeth, close your eyes and don’t let me open them. Cranial nerve
seven, facial nerve is intact.
Can you cover one ear and repeat the words you can hear?
“Whisper blue, green, red”
Ok now cover the other ear.
“Whisper six, seven, eight”
Cranial nerve eight vestibulocochlear nerve is intact
Now stick out your tongue and say “aahh.” Hard and soft palates are pink, moist, intact with no lesions, edema or
drainage noted. Rise and fall of the soft palate and uvula noted. Cranial nerve nine, glossopharyngeal nerve is intact
and cranial nerve ten, vagus nerve is intact.The tonsils are present and are +1, 2, 3, or 4
Can you shrug your shoulders for me? Now do the same while I apply resistance. Cranial nerve eleven, spinal
accessory nerve is intact.
Can you stick out your tongue? Move it up, down, and side to side. Cranial nerve twelve, hypoglossal nerve is intact.
Now I am going to inspect your hair. Hair appears to be evenly distributed with uniform thickness. It is brown with
blonde highlights. It is (clean and straight . The scalp is clean. It is pink, warm, dry, and intact without any obvious
edema, lesions, nodules, hematomas, erythema, flaking, or lice. The scalp is slightly mobile. There is no tenderness
The skin to the face is smooth, pink, warm, dry, intact, without edema, erythema, lesions, nodules present, macule
noted. Patient has a relaxed facial expression and makes eye contact. There is no involuntary muscle movement.
Now I am going to check your lymph nodes.
(Palpate and name lymph nodes)
The preauricular, post auricular, occipital, posterior cervical chain, anterior cervical chain, tonsillar,
submandibular, submental, and supraclavicular lymph nodes are all non-palpable and nontender.
Palpebral fissures at the eye are bilaterally symmetric. Eyelashes are present and equally distributed with slight,
outward curl. Skin to eyelids is intact and pink with no erythema. Eyelids close completely and smoothly and are
without lesions, nodules, or drainage noted. Eyebrows are bilaterally symmetric and are evenly distributed. They do
not have scaly or flaky skin underneath them. Eyes are symmetric and (color). Sclera is white with no lesions or
deformities. Cornea is clear and shiny with no opacities. Conjunctiva is pink and moist. There is no edema or
Now I am going to check your sinuses. Frontal and maxillary sinuses are nontender bilaterally.
Pinna is aligned with the outer canthus of the eye. Ears are normal size. Pinna recoil is appropriate. Skin is pink,
warm, dry, intact and nontender bilaterally. No deformities, inflammation, drainage, or nodules noted bilaterally
(Piercings noted and location if so).
Now I am going to look in your ears. Is that, ok? (Assess internal ear and external ear canal with otoscope) The
tympanic membrane is shiny, translucent pearly gray and canal is without inflammation, lesions, or drainage. Cilia is
present, positive cerumen. It is a small amount, yellow, moist.
Now I am going to inspect your nose. The skin to the nose is pink, warm, smooth, and intact without lesions,
erythema, tenderness, or drainage noted. Nose is straight, midline to face, nostrils are symmetric, without flaring.
Nasolabial folds are bilaterally symmetric. Can you cover one nostril and sniff and now the other? Nares are patent
(Use penlight to look inside)
Nares are clear of obstructions; nasal hair is present and evenly distributed. Septum is straight, midline, and
intact. Drainage is not present. Erythema and lesions are not present.
Lips are symmetric. They are pink, moist, no cracks, lesions, or drainage noted. Upper lip is everted. Can you open
your mouth for me? Teeth are white, 32 are present and intact with no caries noted. The gingiva is pink, moist, no
edema, lesions or drainage noted, and nontender to palpation. The buccal mucosa is pink, moist, saliva is clear,
without lesions, edema, drainage, or odor noted. Can you stick out your tongue? Tongue is symmetric, straight,
midline, pink, moist and slightly rough. Can you lift your tongue for me? Frenulum is present. It is pink, midline,
moist and intact.
Now I am going to check your trachea. The trachea is firm, midline, intact, slightly mobile and nontender. Spacing
is symmetric.
Now I am going to assess your lungs. Patient is sitting upright and straight. Breathing is effortless at approximately
16 respirations per minute. I am now going to listen to your lung sounds on your back.
If you get dizzy at any point, please let me know and we can stop. Every time you feel my stethoscope move; I want
you to take a deep breath. (Move stethoscope across ten areas for lung sounds) Patients posterior lung sounds are
clear bilaterally with no adventitious sounds heard. No use of accessory muscles. Bronchovesicular sounds heard
here (upper), vesicular sounds heard here (lower). Rise and fall of the posterior chest wall is bilaterally symmetric.
The skin is pink, warm, dry, intact with no obvious lesions, deformities, or nodules. The ribs have normal curvature.
There are macules and tattoos noted.
Now I am going to listen to your anterior lung sounds. Just breath normally ok. (Move stethoscope across the 8
anterior lung locations) Patients anterior lung sounds are clear bilaterally with no adventitious sounds heard. There is
no use of accessory muscles. Bronchial sounds are heard here (near trachea), bronchovesicular sounds are heard here
(upper) and vesicular sounds are heard here (lower) Rise and fall of the anterior chest wall is bilaterally symmetric.
Skin is pink, warm, dry, intact with no obvious lesions, deformities, or nodules noted. There are macules noted.
Now we are going to go through your cardiovascular system. Bilateral upper extremities are pink, warm, dry, intact
with no erythema, edema, lesions, or nodules. There are macules and tattoos noted. The hands are bilaterally
symmetric. Bilaterally the nail beds are free of erythema, lesions, drainage. Bilaterally the nails are pink, clean,
smooth, slightly round, approximately 160 degrees. No clubbing noted. Capillary refill is bilaterally symmetric and
less than 3 seconds. Can you squeeze my hands, pull me toward you and push me away? Bilateral upper extremity
strength is +5. Grip strength is bilaterally +5. The bilateral lower extremities are pink, warm, dry, intact with no
erythema, edema, lesions, nodules or deformities. The nail beds are free of erythema, edema, lesions, or drainage.
The nails are pink, smooth, round and capillary refill is less than three seconds. Can you push me away (hand on
shin)? Can you pull me toward you (hand on calf). Bilateral lower extremity strength is +5.
Now I will be touching your face. Temporal pulse bilaterally equal, regular +2. Carotid pulses one at a time are
bilaterally equal, regular +2. Radial pulses bilaterally equal, rhythm approx 80bpm, regular +2. Brachial pulses
bilaterally equal, regular +2. Dorsalis pedis pulses bilaterally equal, regular +2. Posterior tibialis pulses bilaterally
equal, regular +2.
At this time, I am going to listen to your heart. Aortic valve at the second intercostal space right sternal border S2
heard best, Pulmonic valve at the second intercostal space left sternal border S2 heard best, Erb’s point at the third
intercostal space left sternal border S1/S2 heard equally, Tricuspid valve at the fourth intercostal space left sternal
border S1 heard best, Mitral valve at the fifth intercostal space left midclavicular line S1 heard best. Now we are
going to listen for bruits. No bruits heard bilaterally at the carotid arteries. Now we are going to listen for murmurs
and splitting in the chest. No murmurs and no splitting noted. The point of maximum impulse is at the 5 th intercostal
space left midclavicular line it is noted to be about dime size without thrills. No signs of heaves, lifts, or retractions
noted at the pericardium upon inspection.
Now if I can have you lie down, I am going to access the abdomen.
Patient’s abdomen is flat. It is pink, clean, dry, and intact with no erythema, lesions, or nodules noted. The umbilicus
is midline and intact. There is scarring present on the abdomen. No visible peristalsis or pulsations noted. Now I am
going to listen for bowel sounds. Patient’s bowel sounds are present in all four quadrants and are normoactive.
(Listen to the aorta for bruits with bell) There is no bruits heard at the aorta.
Now I am going to have you flex your knees and I will be pressing on your stomach. Again, let me know if you have
any tenderness or pain. (Lightly palpate abdomen)
Patient’s abdomen is non tender to palpation with knees flexed and abdominal muscles relaxed. Now I’m going to
press a little deeper. There are no masses, nodules, or pulsations palpated.
Now if you will relax your legs and do half of a crunch. There’s no herniations noted.
While you are lying down, I just want to inspect your jugular vein as well. Position bed to 45-degree angle and shine
light. (Do on right and left side) Patient is at a 45-degree angle, no jugular vein distention or pulsations noted.
Test deep tendon reflexes.
Triceps-triceps reflex intact, normoactive +2
Biceps-Biceps reflex intact, normoactive +2
Brachioradialis- Brachioradialis reflex intact, normoactive +2
Patellar- Patellar reflex intact, normoactive +2
Achilles- Achilles reflex intact, normoactive +2
We are going to check your range of motion, so I just need you to repeat the things that I do.
Neck: Flexion, extension, lateral flexion, lateral flexion, with resistance. Strength equal bilateraly +5
Arms: Flex, extend, hyperextend, abduction, adduction, external rotation, internal rotation. Flexion, extension,
pronation, supination
Wrist: Flexion, extension, hyperextension
Fingers: Flexion, extension, hyperextension, opposition, reposition
Hips: rotate side to side, bend
Legs: Flexion, extension, hyperextension, abduction, adduction
Other side: Flexion, extension, hyperextension, abduction, adduction
Knees: Flexion, extension
Feet: Plantarflexion, dorsiflexion, eversion, inversion
Now I need to look at your vertebral column, so I am going to have you bend at the waist. Vertebrae are straight,
there is no tenderness noted upon palpation.
Romberg test- Romberg test is negative
Heel to Toe-Gait is stable, smooth, and coordinated
Stand on One Foot with eyes opened and closedCerebellar and motor function intact