Head to toe assessment for CPE / 242 / Drayton

Hello, my name is _______, I am a nursing student here at Galen College
of Nursing. (Go wash hands) I am going to be conducBng your head-totoe physical assessment that the doctor ordered. Pull curtain for privacy.
Can you state your full name for me? Do you have any allergies to
medicaBons? Latex? Food? Conduct a side-by-side comparison with the
paBent’s armband and doctor orders, verbalizing the paBent NAME,
MRN and DOB.

Like I said I am here to do a full physical assessment, I must expose you
and touch you in some areas, are there any cultural consideraBons I need
to be aware of? I will be assessing your lungs, your heart, skin, listening
to your tummy. Do you have any quesBons for me? Okay let’s get started
then.

Raise the bed to a comfortable working height, drop side of bed, remove
call light. Raise the head of the bed to at least 30 degrees. (Wash hands)

So, the Wrst thing I am going to do is look at your head and face. I do see
that your eyes are symmetrical, your nose is midline, your ears are
symmetrical. I will be touching your head and your face, is that ok? I am
touching your head are you experiencing any pain or tenderness as I am
touching? I am looking at the scalp for any lesions, excessive dandruX
and palpaBng for bumps, lumps or edema. State it is free from any
vermin and hair is eventually distributed and skin is in-tact to the scalp.

I am now going to palpate your face, any pain or tenderness? (Forehead,
sinus area). Palpate maxilla and jaw area for pain or tenderness. Note
paBent’s skin is warm, pink dry and in-tact.

Checking behind the ears, any pain behind your ears? I am going to ask
that you turn your head to the leZ, using my pen light I will inspect your
ears. No signs of excessive cerumen, since your head is already turned, I
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am going to assess for jugular vein distenBon, there is none noted. I am
going to assess your right caroBd, noted that it is +2 and regular. I am
going to have you turn your head to the right side, again using my pen
light I note no excessive cerumen or drainage in the leZ ear, no jugular
vein distenBon and the leZ caroBd is +2 and regular.

Let’s move your head straight. I am going pull down your eyelid. I note
that the sclera is white, conjuncBva is pink, there is no excessive drainage
noted. Using my pen light, I am going to look in your nostrils note the
septum is midline, the nasal mucosa is in-tact and no drainage or polyps
noted.

Looking in paBents mouth at oral care. Ask if those are all of your natural
teeth? Oral mucosa is intact, pink and moist and no drainage noted.
Uvula is midline. Note the skin to his lips are intact. I note the trachea is
midline.

Ask permission to pull down paBent gown to expose chest. State I will be
listening to your lungs and your heart. First, I will be inspecBng your
chest, it is noted that chest rises and falls equally. Chest hair is equally
distributed through thoracic cavity. No bumps, lumps and all skin is
intact. There are no laceraBons or hematomas and skin is warm, pink, dry
and in-tact.

I will now be placing my stethoscope on your chest, every Bme I place it
on your chest, I need for you to take a deep breath in.
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o Auscultate (listen) neck for tracheal sounds. Then bronchial x 2,
bronchial vesicular x 4, vesicular x4 (10 sites total)
 With help of my UAP I am going to sit you up to listen to your back. (10
sites) Avoid boney prominent, scapula and spine. I need you to take a
deep breath each Bme I move my stethoscope. Bronchovesicular x6,
vesicular x4

 I am going to idenBfy some landmarks of the chest. I have the
suprasternal notch (right above sternum), 3 Wnger widths down is the
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angle of Louie. The AP diameter is 1:2 (place hand on side, then 2
across the chest). (Phoenix bird with hands) Place hands with thumbs
in - in a phoenix posiBon on the chest state that the costal angle is less
than 90 degrees.
 Now I am going to listen to your heart sounds. We are listening over
the aorBc valve at the second intercostal space, right sternal border.
Second intercostal space leZ sternal border is the pulmonic valve. 4 th
intercostal space, leZ sternal border is the tricuspid valve. Using the
bell of my stethoscope at the 5th intercostal space, leZ mid clavicular
line is the mitral valve and where I would obtain an apical heart rate.
Listening for a full minute the apical heart rate is 86.
 Checking for brachial pulse on both sides of arms simultaneously.
Brachial pulses are +2 equal and regular bilaterally. Radial pulses are
+2 equal and regular. Assessing the skin on the arms. Skin is warm,
pink, dry and intact. The hair is evenly distributed on the leZ and right
arms, and no edema is noted.
 Ask paBent to liZ their right arm oX the bed, are you able to bend at
the elbow? Ask if experiencing any pain in that locaBon. Touching the
shoulder ask if any pain at the shoulder or wrist. State I note no
excessive warmth or crepitus in those areas. (Have pa=ent close eyes)
Grab paBents thumb and ask if he knows what Wnger and side of his
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body you are touching. Check for capillary reWll, state it is less than 3
seconds.
 Ask paBent to liZ their leZ arm oX the bed, are you able to bend at the
elbow? Ask if experiencing any pain in that locaBon. Touching the
shoulder ask if any pain at the shoulder or wrist. State, I note no
excessive warmth or crepitus in those areas. (Have pa=ent close eyes)
Grab paBents thumb and ask if he knows what Wnger and side of his
body you are touching. Check for capillary reWll, state it is less than 3
seconds.
 I am going to assess for strength - Have paBent squeeze both of your
hands checking for equal strength on both sides. Have paBent push
against my hands (pafy cake). Strength, grips and pushes bilaterally in
upper extremiBes are equal. Look for skin turgor (pinch top of skin on
hand and look for “ten=ng”). State, no tenBng noted.
PUT HEAD OF BED DOWN FLAT
 State, I am going to expose your abdomen area. First thing I am going
to do is inspect abdomen, noBng abdomen is round, there are no
pulsaBons noted. (Wash hands and put on some gloves)
 I am going to auscultate bowel sounds in 4 quadrants. Listen to all four
quadrants of abdomen starBng at right lower abdomen and moving
clockwise. Right lower (listen one full minute), Right upper (listen one
full minute), LeZ upper (listen one full minute), LeZ lower (listen one
full minute). State paBent exhibited normal, acBve bowel sounds in all
four quadrants.
 I am going to palpate your abdomen, let me know if you experience
any pain as I do this. RLQ, RUQ, LUQ, LLQ.
 Ask when was your last bowel movement? What color was it? How
oZen do go? Did you have any pain when you went to the bathroom?
Any abnormal odor? Was it small, medium or large? What was the
consistency?
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 I am now going to inspect the bladder, no bladder distenBon noted. I
am going to be pressing down, let me know if you experience any pain.
Palpate across bladder from right-middle-leZ. It is noted that skin is
warm, pink dry and in-tact. Any pain or tenderness when I palpated?
Ask, when was the last Bme you urinated? What color was it? Any pain
upon urinaBon? Did it have an unusual odor? Did you see any parBcle
hoaBng in it?
 I am going to assess femoral pulses now, they are +2 equal and regular.
For the genital assessment, I see that the hair is evenly distributed,
there is no foul odor or drainage noted.
Remove gloves and wash hands!!
 Pull covers down and expose paBent legs, check skin, noted that it is
warm, pink, dry and intact. State that hair is equally distributed, no
lumps, bumps or laceraBons and no edema noted bilaterally.
 StarBng with right leg ask paBent to liZ leg oX the bed, bend at the
knee ask if feeling any pain at the hip, knee or ankle? State no
excessive warmth or tenderness or crepitus noted.
 Ask paBent to life leZ leg oX the bed, bend at the knee. Ask if feeling
any pain at the hip, knee or ankle? State no pain, excessive warmth or
crepitus noted.
 Ask paBent to close their eyes, can you let me know where I am
touching? Touch one toes on the Bp in each foot. You can open your
eyes now. I am assessing cap reWll on each foot, it is less than 3
seconds. Assessing popliteal pulses bilaterally they are +2 equal and
regular. Posterior Bbialis +2 equal and regular. Dorsalis pedis +2 equal
and regular.
 Ask paBent to press down on my hands with both feet like pressing on
a gas pedal. Put hands on top of feet, ask paBent to resist by pulling
back. State pushes and pulls in lower extremiBes were equal and
bilateral.
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 Ask paBent to bend at the knee and we are going to turn to the leZ
side. I am noBng that the skin is warm, pink, dry and intact. There is no
breakdown at the back of the head, no sacral edema, skin to the heels
is intact.
 Place socks on paBent, check radial pulse for 1 minute, state pulse is
82. Ask paBent if they can sit up on the side of the bed. PUT BED
DOWN IN LOWEST POSITION
 While paBent is sikng on the side of the bed, check radial pulse again
noBng that it is 84. Ask paBent if they are having any dizziness or
lightheadedness? Stand paBent up while assisBng him, making sure
paBent is not dizzy.
 Ask paBent to take 5 steps forward, turn around and look at me and
take 5 steps back towards me, checking paBent’s gait. Does not exhibit
any limping or abnormaliBes. Ask paBent to bend at the waist before
he sits down, state I am assessing for lordosis, kyphosis and scoliosis.
None is noted and again gait is steady.
 Assist paBent back into bed (take socks oC). State I have concluded
physical examinaBon. Ask paBent if they have any quesBons. Cover
paBent with blankets, give pillow back under head.
 Lower bed to lowest posiBon, make sure both handrails are up, Place
call light in paBent hand, open curtain.
 (Go wash hands)
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