Intro
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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
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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
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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
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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*
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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
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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
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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
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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
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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
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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
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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
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Palpate carotid pulses
o Pulses are +2 amplitude with a regular rate and rhythm and appear symmetric
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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
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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
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I will deep palpate for the liver and spleen looking for Murphy’s sign
Musculoskeletal
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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
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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