SCRIPT FOR RD PHYSICAL ASSESSMENT
Good morning ma'am! I am student nurse Danica Nuevaexcija and today I will be performing return
demonstration on the physical examination or physical assessment. For the preparation phase, I'm going
to introduce myself to my client. The rationale for this is to gain trust and make the client comfortable.
Prior to the conduct of the procedure, I must perform proper hand hygiene and put on necessary PPE and
provide privacy this is to avoid interruptions. I also have to verify my patient’s identity this is to ensure
that
I
am
doing
the
assessment
to
the
right
patient.
“Good day ma'am I am Danica Nuevaexcija, your student nurse. I would like to verify your identity kindly
state your name and your birth date for me? How would you like me to address you ma'am?”
“OK miss Kyla, so I'm going to conduct physical assessment to you to ensure that everything is normal and
I'm also I'm going to take note if there are any symptoms or risk factors so that we can refer you to your
doctor before it gets worse. I assure you that everything that is written is kept confidential. Do you have
any questions ma’am before we begin?” “Okay so first, we’re going to obtain your height, weight and
check your vital signs”
INTEGUMENTARY
I’m going to assess my patient's history if there are any lesions, rashes, and trauma by checking the
patient's skin color (signs of pallor, cyanosis, jaundice and erythema), odor, and palpate for skin
temperature,
turgor,
texture,
moisture,
tenderness,
and
blanching.
As I am inspecting the skin of my patient, there are no skin lesions, bruises or patches and the skin color
is light brown which is normal. If there are any findings, note for shape, size, and color.
Next, I'm going to palpate the skin temperature using the back of our palm as we are trying to feel any
signs of fever and signs of infection. “Ma’am I'm going to put my hands now” I don't feel any signs of fever
and signs of infection and it seems that my patient has a normal temperature.
Next, I'm going to palpate for texture and moisture. Signs of excessive dryness and excessive moisture
indicates abnormalities, and we must take note of that. In assessing the turgor, I am going to pinch the
skin of the client. If the skin returns in just 2-3 seconds then it is normal. But if not, there are presence of
skin turgor that indicates dehydration.
Next is the palpate for edema. In assessing edema, you have to put pressure on the skin if the skin
becomes indented, it means there are signs of edema. But if the skin quickly returns to normal, it has no
signs of edema. “Ma'am can I ask you to raise your foot” based on my assessment the client has no sign
of edema.
Next I'm going to assess the nails of my client. Nails often provide important clues about the patient's
overall health status. “ma'am can you raise your hands like this” inspect the nail color, shape, texture, and
signs of nail clubbing. Base on my Inspection, the nails of my client are normal and there are no signs of
nail clubbing or brittleness of the nails. Next I'm going to inspect for the capillary refill and to do that
apply pressure on the nails to our client. If the color quickly returns so it's normal color then there are no
signs of abnormalities. If not then the client has slow capillary refill.
Now I'm going to assess my patients hair and scalp. to do that we have to don clean gloves. check if there
are signs of lesion, infestation of the scalp, and the hair. Based on my inspection, the hair of my client
seems healthy , she has silky and thin hair and the scalp is normal. There are no signs of lice, dandruff.
HEAD AND FACE
So now I'm going to assess my patient’s head and face. Inspect for its size, shape, symmetry, facial
appearance and features and palpate for tenderness and masses. “Miss Kyla, do u feel any discomfort or
pain in your face and head? Have you noticed any noticeable changes?” “I'm going to proceed for the
inspection na ma’am ha”. As what I have noticed, my clients head is symmetrical and round. there are no
nodules or masses when palpated.
Now for the face. “can you raise your eyebrows for me ma’am” “can you smile for me ma'am” so it seems
that the face of my client seems normal in terms off the color, facial features are symmetrical, and no
scars. If you notice any drooping in the face that may indicate stroke or bell’s palsy so I have to take note
for that. And lastly I have to inspect the overall skin coloration of my client for any signs of jaundice,
cyanosis, pallor, or erythema.
EYES
Next I'm going to assess my client's eyes. First I'm going to inspect the external structure of the eye’s
general appearance such as eyelids, lashes, lacrimal glands and ducts, conjunctiva and pupils. “miss Kyla
do you have any troubles in your eyesight? Have you had any eye surgeries before? on the wall do you
feel any discomfort??” “so now I will be inspecting your external eye these includes your eyelids,
eyebrows and eyelashes.”
As what I have notice, the eyes of my client is normal, eyebrows are in equal position, there are no signs
of swelling, skin lesions, and thinning of eyelashes which is good. Now I’m going to inspect the conjunctiva,
cornea and the sclera of the client. I’m going to test the corneal reflexes by shining the light of my penlight
just in the middle of the nose of our client. Inspect the spot where the light is being reflected. if the light
is reflected at the same spot then it is normal if the light don't reflect at the same spot it's abnormal and
indicates strabismus the condition in which the eyes do not line up with one another. Next, I'm going to
inspect the conjunctiva and the sclera of the client. Noting the color of the sclera because sclera becomes
yellowish it indicates jaundice and jaundice indicates hepatitis, so we have to prevent further
complications. Also note for swelling of edema especially in conjunctiva, if it is present, it indicates
chemosis (sign of irritation). We also have to take a look with bulbar conjunctiva by asking our client to
look up as we pull the eyes downwards and look down and pull her eyelids upwards.
“Ma’am I'm going to touch your face is that OK with you? try to look up for me ma'am and look down”
based on my inspection bullbar conjunctiva is good and normal.
Now I'm going to perform the cover uncover test to check the alignment of the eye of my client. If the
client shows sign of esophoria, which means when you move an object going to the eyes of the client, the
eye moves outward, esophoria is when the eyes move inward but the alignment of eyes are normal, it will
stay still. “Ma’am I’m going to put this card above your eyes and sundan niyo lang po okay?” So my patient
shows no signs of esophoria and it’s good.