Introduce yourself

(close curtain )

“Hello, my name is Madison, I will be your student nurse for today.”

“What is your name?”

“Okay Shayla, how old are you?”

“Can you tell me what building you are in?”

“Can you tell me what day it is?”

“Okay good! What brings you here today?”

“On a scale from 0 to 10, 0 being no pain, can you tell me how much pain you are in?”

“okay good! So as i walked in i noticed that your gait was smooth. You are alert and orient to

person, time, place, and situation. Your speech is clear and articulate. Your behavior is

appropriate and you are dressed appropriately for the weather.”

“Now I am going to start your head to toe assessment!”

Head

- Inspect — symmetrical, no edema is present, no lesions, appropriate distribution

- Palpate— no masses, tenderness?, no lesions, hair is clean, no brittleness, no excessive

dryness or moisture

Face

- Inspect — Face is symmetrical with no lesions, color is even throughout, no edema

- Palpate— sinuses— any tenderness?

- Temoral pulse— 2+ normal

- TMJ— no crepitus

- Eyes:

- inspect: sclera (clear and white)

 - conjunctiva (pink and moist)

- no lid lag, lid movement is normal

- pupils start with a 4 then shine light (pupils go down to a 2)

- (shine penlight) pupils constrict to light (indirect and direct)

- Pupils accommodate

- Nose:

- Palpate, (use penlight)— inside nose pink, moist, and no lesions

- Septum (no deviation is present)

- Ask them to press on one side then other— Patent— bilaterally

- Mouth:

- Pink, moist, no dryness or cracking

- teeth: intact, good hygiene, no chipping

- Buccal mucosa: pink, moist, no lesions

- Tongue: pink, wet, no lesions

- Sublingual: pink, moist, venous

- Ears

- palpate— pinna, tragus, lobule

Neck

- lymph nodes

- Pre-auricular

- Post- auricular

- Occipital
 - Jugulodigastric

- sub mental

- submandibular

- superficial cervical

- posterior cervical

- deep cervical chain

- supraclavicular

- Carotid pulse— 2+ normal

- Bruit— no bruit present

- ROM— flexion, extension, side, side (then with pressure)

Shoulders

- Move arms in front, side (again with pressure), rotate

- Fingers-to-nose (coordination)

Elbows

- flexion, extension (again with pressure)

Arms

- Palpate down arm bilaterally for temperature (warm and dry, no excessive dryness or

moisture)

- Brachial pulse— 2+ normal

- Radial pulse— 2+ normal

- Hands

- Turgor — no tenting present

- Nails are well groomed

- Capillary refill less than 3 seconds

- No clubbing (thumbs together)

- Move wrist down, up, then rotate

- Grasp hands

- Finger- to thumb (coordination)

Respiratory System

- Chest expansion— equal bilaterally

- A & P ratio is 2:1

- Patient is able to breathe comfortably without visible difficulty

- Auscultate: 4 in front, 2 on side and 4 on back (no adventitious sounds are present)

- Cardiovascular System

- Aortic Valve: 2nd intercostal space, right sternum border

- Pulmonic valve: 2nd intercostal space, left sternum border

- Tricuspid valve: 5th intercostal space, left lower sternum border

- Mitral valave: 5th intercostal space, left mid-clavicular line

- (diaphragm then bell)

- Laying down

- 45 degree angle— check for JVD (NO JVD) and carotid pulse (visible)

- Lay flat:

- Apical impulse (palpable and visible)

- Abdomen
 - Inspect: contour, flat, partially rounded, no lesions or masses, symmetrical , no visible

pulsations

- Auscultate: 4 quadrants start at RLQ — all quadrants are normative

- Percuss: tympani on all four quadrants

- Palpate: outside then inside on all four quadrants — any tenderness?

- Femoral pulse— note location

- Check temp down leg

- Check edema in leg

- Palpate popliteal pulse— not palpable

- Palpate posterior tibial pulse— 2+ normal

- Palpate dorsalis pedis— 2+ normal

- check for clubbing, nails well groomed, capillary refill less than 3 seconds

- point toes, flex feet, rotate ankles

- Lift up legs, lift up knees, lift legs with resistance

Sit up

- patellar knee reflex

Stand up

- Spine

- Bend over- palpate curvature, no deviation, no tenderness

- bend back, side, side

- walk heel to toe (tandem walking)

- Stand up with eyes closed for 20 seconds (romberg test)