Intro Hi there my name is Kaitie and I will be your student nurse for today I will be performing a head to toe assessment on you and it should take about 30 minutes is that okay with you? Can I please get your name and date of birth please? Provide privacy Perform hand hygiene Do you have any allergies? On a scale of 0-10, 0 being no pain, 10 being the worst pain, are you in any pain right now? General Appearance Physical appearance is consistent with age Posture is upright and symmetrical No signs of acute distress Facial expressions, mood and affect are appropriate with situation Speech is clear Dress and personal hygiene are appropriate Can you please tell me where you are right now? What day of the week is it? Why are you here? Patient is alert and oriented to person, place, time and situation No visible devices or physical deformities noted Skin and Nails Skin color is consistent throughout No lesions, wounds, incisions or piercings noted Palpate the skin with the backs of my hands for temperature The fronts of my hands for moisture Skin is warm, dry and intact throughout Please stick your hand out for me so I can assess for turgor…. No tenting noted Color, shape and contour of nails are consistent throughout Hold down finger to 5 seconds to test for cap refill…capillary refill occurred in less than 3 seconds Head, Face, Neck Facial structures appear symmetrical I will inspect for infestations behind the ear and nape of the neck. None noted No lesions noted Please let me know if any of this is painful *palpate head* Please close your eyes. I will touch your face with a cotton ball and please point to where I touch after I do so. I will be putting my hands on your jaw. Please open and close your mouth multiple times o Cranial nerve 5 is intact Please smile, frown, puff cheeks out and put your tongue to your cheek on each side o Cranial nerve 7 is intact I will be placing my hands on your shoulders, please shrug them against my resistance o Cranial nerve 11 is intact Trachea and thyroid appear intact and midline I will be palpating your lymph nodes, please let me know if you have any pain or tenderness o Preauricular o Postauricular o Occipital o Tonsillar o Submandibular o Submental o Posterior cervical chain o Deep cervical chain o Superficial cervical chain Lymph nodes are non palpable and non tender bilaterally Eyes No discharge, redness or lesions on external ocular structures Eyebrows, eyelids and eyelashes are intact and symmetrical Conjunctiva appears pink and moist Sclera appears white Snellen and Rosenbaum test would confirm cranial nerve 2 intact I will now check my patients six cardinal fields of gaze using the wagon wheel method Pupil size is approximately 3 mm I will test the pupils for reactivity to light and accommodation Cranial nerves 3, 4, and 6 are intact PERRLA Ears There does not appear to be any lesions on the external structures of the ears Please let me know if you have any pain when I palpate o Pinna o Lobule o Tragus o Mastoid process The tympanic membrane is pearly gray, translucent, flat and intact I will now perform the whisper test, please cover the opposite ear Please stand up and put your feet together, hands to your sides and close your eyes (Romberg test) Cranial nerve 8 is intact Nose Please close your eyes and tell me what you smell Cranial nerve 1 is intact The nose is proportionate to face, position is midline, and is symmetrical There appears to be no deformities, asymmetry or inflammation internally No drainage noted Please cover one nostril and breathe deep, and the other nostril, breathe deep o Bilateral patency notes Mouth and Throat Lips appear pink and moist Tongue, gums, buccal mucosa, soft palate all appear pink and moist Teeth are all intact, no dentures notes Please open your mouth and say “AHH” (I would do this while sticking a tongue depressor in their mouth to check for gag response) o Cranial nerve 9 and 10 are intact No signs of pharynx redness or drainage Please say “light, tight dynamite” Cranial nerve 12 intact Respiratory System It appears no accessory muscles are being used to breathe I will auscultate the anterior lung fields using the side-to-side pattern. My landmarks are the clavicles and the sternum. Lungs are clear and equal throughout bilaterally. No adventitious breath sounds noted AP:T is 1:2 Costal angle is 90 degrees I will no auscultate posterior lung fields using the side-to-side pattern. My landmarks are the scapulae and the spine Lungs are clear and equal throughout bilaterally. No adventitious breath sounds noted Please say “99” every time I place my hands on your back No tactile fremitus noted, vibrations decreased as my hands went down patients back. Cardio/Peripheral Vascular Palpate carotid pulses o Pulses are +2 amplitude with a regular rate and rhythm and appear symmetric Auscultate carotid arteries o No bruits noted Turn your head to the left, then to the right (at 45 degree angle) o No JVD, heaves or pulsations noted I will palpate for the clavicle o Down to the first intercostal space o Second intercostal space Using the diaphragm of my stethoscope, auscultating the aortic valve in the second intercostal space, right sternal boarder, S2 is greater than S1 Moving over to the left sternal boarder, second intercostal space, Pulmonic valve, S2 is greater than S1 Moving down one to the third intercostal space, Erb’s point, S1 and S2 are equal Down another to the fourth intercostal space, tricuspid valve, S1 is greater than S2 I am going to feel for the apical pulse by moving breast tissue out of the way with the back of my hand, thumb tucked Now going to the fifth intercostal space, mid clavicular line on the left, mitral valve, S1 is greater than S2 I am going to palpate for a radial pulse to feel and listen for a pulse deficit. o No pulse deficit noted I am going to switch over to the bell of the stethoscope to listen for murmurs No murmurs noted for the mitral valve No murmurs noted for the aortic valve No murmurs noted for the pulmonic valve Skipping Erb’s point No murmurs noted for the tricuspid valve I will now palpate radial pulses simultaneously Rate is regular, rhythm is strong not bounding and they appear symmetrical I will now palpate the posterior tibialis and dorsalis pedis pulses o Both have +2 amplitude, with regular rate and rhythm and appear symmetric If I could not find the pulse I would then use a doppler Hair distribution on the legs is appropriate, there is no edema present Gastro/Urinary Abdomen appears symmetric, no distention or scars noted I will auscultate for the abdominal aorta and venous hum o No bruits noted o No venous hum noted Starting in the RLQ I will auscultate for bowel sounds Moving to the RUQ LUQ LLQ I will now palpate all quadrants looking for o Tenderness, distention, guarding, masses and rigidity I will deep palpate for the liver and spleen looking for Murphy’s sign Musculoskeletal I will inspect the elbow joint & the wrist joint o Appears symmetric o Range of motion is appropriate o Reflex near the tricept is intact I will inspect the knee joint & ankle joint o Appears symmetric o Range of motion is appropriate o Reflex near the patella is intact I will assess for spinal abnormalities o No kyphosis, lordosis or scoliosis noted Please push your hands against mine Please push your shines against my hands If you could stand up and walk to the door and back please o Gait is intact and appropriate Please run your heel up your shin & now the other side Please copy what I do with my hands on your lap as fast as you can (rapid hand movement) o Coordination is intact Closure How is your pain now? Do you need anything else to make you feel more comfortable? Bed in lowest position Side rails up Bed locked Call light Thank you Hand hygiene Done