Head-to-Toe Assessment Script

I'm going to be observing the patient's skin throughout the exam. Your facial features look symmetrical.

Face have pt smile or frown show your teeth?

Palpate femoral pulses

verbalize only grade it

Documenation

wash hands and document

I'm going to take a listen to your lung sounds now. (alcohol swab the stethoscope). When you feel the stethoscope on your skin, please take a deep breath in and out with your mouth open. if you feel dizzy please let me know. (start at C7 and move down, side to side. make sure to hit RML)

Normal breath sounds are present and clear in all fields. I don't hear any crackles or wheezes, no adventitious sounds to indicate lung disease.

Light palpate on Abdomen

Palpate abdomen soft firm distention Palpate for tenderness non masses bladder distension

oxygen saturation (SpO2)

Position probe correctly Read pulse oximetry reading normal rate 95-100% use of supplemental oxygen & flow rate

Can you walk to the door and back?

Posture upright Gait steady No use of assistive devices like canes or walkers

hair distribution

Thinning, balding, alopecia, use of wigs quantity thickness texture oily dry fine shiny coarse The scalp does not have any lesions or pest inhabitants.

Muscle strength of arms sensation

hand grasps strength equal on both sides close eyes can you tell me is this sharp or dull? move upper arms up and down presence of numbness tingling

blood pressure (BP)

measure & applies appropriate size cuff 40 width & 80 length Palpate radial or brachial artery place cuff on by doing the 2 step method Measure and state BP

NVD PULSATIONS Trachea Carotids

neck vein distention Carotid absent or visible Trachea midline ROM head up and down side 2 side palpate carotid garde it +2 Bruit tell Pt to breathe in and out listen with bell

Mouth, Lips Tongue Speech

Drooping of mouth or lips Tongue midline check color moisture of mouth lips mucous membranes lesions or sores in mouth Condition of teeth dentures speech clear

LOC level of consciousness

A patient's mental status due to illness or injury Alert Does the Pt know where they are? Who is the President of the USA? What brought them to the hospital ? Oriented X4 Is the pt sad, angry, nervous, or happy

Leg muscle tone / strength sensation

Ability to move legs freely flex extend strength song equal on both sides muscle strength and tone dull or sharp twest numbness or tingling

face Skin / Edema Check for sinuses push eyebrows up

Brown, dark brown , tanned , fair tone, pale white tone , freckles , wrinkles rosey cheeks pink Palpate for periorbital edema Good, the eyes, lids and lashes are all healthy. Palpate temporal artery and grade

Pain PQRST

Ask PT to point to pain P-provokes anything make it better or worse Q-quality R- radiation does it go anywhere S-severity 1-10 T-timing onset, how long, coming & going Is it tolerable or not tolerable

Chest skin

Assess skin color conditions temperature and moisture edema grade

DVT (deep vein thrombosis)

Check calf for tenderness or pain redness warmth edema

Voiding pattern questions

Frequency? Burning or pain with urination? Urine Color and clarity? Amount? Hesitancy or urgency? Bleeding or blood in urine?

Can you tell me how much you weight and your height? Any recent weight gain or loss? Appetite diet problems eating? Nausea or vomiting?

Heartburn? Use of supplements? Problems swallowing or chewing?

bowel sounds make sure Pt is laying flat

Intestinal sounds heard from auscultating over the abdomen; active, hyperactive, hypoactive, diminished, absent, tympanitic x4 quadrants

BM Patterns

Last BM DESCRIBE SHAPE GAS

Radial pulse site chack pulse for 30 sec than multiple by 2

Located at the wrist on the thumb side Rate Rhythm regular or irregular Strength +2 Normal range 60-100 beats

I'm going to listen to the lungs from the front now. As you feel the scope on your skin, please take a deep breath in and out and let me know if you feel dizzy. don't forget lung sounds on the side

Lungs sound clear and normal breath sounds are present in all lung fields. There are no crackles or wheezes. its Bronchial Your lungs sound very healthy

Nose/Ears

Nasal flaring color of nose presence of drainage ears symmetrical color of ears drainage hearing aids?

Have you exercised, smoked, or eaten or drank anything in the last 30 minutes? Do you have a history of a mastectomy? Do you have a dialysis shute or A/V fistula? Is there an arm that should not be used?

Now began taking vitals TMR Thermometer probe in posterior sublingual pocket Support thermometer probe have patient close mouth Normal range of 96.8 F -100.4 F

Wash hands give privacy My name is Aleena and I'm a nursing student from Mercy College. I'm going to be conducting your head-to-toe examination. Do you have any questions for me today?

Okay, let's get started then. Can you state your full name for me? And what is your data of birth?

eyes

Pupils size Pupils equal Pupils round Pupils reactive to light Direct response to light Indirect Consensual response to light Accommodation convergence Constriction Sclera white Conjunctiva color pink no drainage

respiratory rate check for 30 than multiple by 2

Rate Rhythm regular Depth Moderate Character Unlabored Use of accessory muscles Normal 12-20 breaths

I'm going to compare your pulses now. can you hold out your hands for me, palm up? good, both pulses are present and equal bilaterally. pulse strength is normal. (capillary refill) the color comes back quickly when i pinch your nail bed. you have good circulation in the arms and hands.

Reflexes +2 on each side

Apical pulse location listen for 60 sec

Sternal notch manubrium angle of Louis Intercostal spaces sternal borders Mid clavicular line, 5th intercostal space All your heart sounds are present and you have a regular rhythm. I'm hearing S2 at the base and S1 at the apex and I do not hear any murmurs. Your heart sounds healthy.

Palpate popliteal pulse

grade it

Palpate the posterior tibial pulse

grade it

capillary refill for toes

after blanching nail bed, color should return to normal withing <3 secs

abdomen skin

check skin color scars tattoos piercings masses incisions contour of stomach flat distended

Arm Skin

color moisture edema skin turgor

Skin for legs

color moisture edema wounds or ulcerations hair distribution

Palpate dorsalis pedis pulse

grade it