Head to Toe Script

Gather supplies

-pen light

-tongue blade

-stethoscope

-reflex hammer

-gloves

-hand sanitizer

Introduce yourself

Provide privacy

Hi, my name is Tim and I am a student nurse.

May I check your ID band to confirm your name and DOB?

I will perform your head-to-toe assessment and I will touch you, is that okay?

Raise bed to working height and have pt sit to edge of bed

Hand hygiene for 20 secs

Head and Scalp Inspection

Upon inspection, the head is normocephalic and symmetric bilaterally. No microcephaly. Scalp is intact and smooth. No flakiness

Head and Scalp Palpation

Do you feel pain or tenderness when I palpate? Scalp is free of lesions. Pt reports no tenderness

Inspect hair

Upon inspection, the pt's hair is equally distributed. No uneven distribution. Hair is black. The texture is thick and no evidence of alopecia

There is no lice on the scalp, behind the ears, and nape of the neck.

Skin is intact with no erythema.

Inspect face

Pt has an oval face. Facial features and bone structures are symmetrical bilaterally

Palpebral fissures of eyes and nasolacrimal folds are symmetric bilaterally with no signs of Bell's palsy

Pt's facial expressions are relaxed. No signs of tics

Assess CN VII

Ask to wrinkle forehead

Raise eyebrows

Puff cheeks

Smile with teeth

Smile without teeth

Frown

Purse lips

Whistle

CN VII is intact

Inspect external structures of eyes

Upon inspection, the outer canthus of the eyes are aligned with the pinna of the ears

Eyebrows and eyelashes are symmetric bilaterally and evenly distributed. There is no hair loss or asymmetry

The eyebrows extend over the eyes and eyelashes are curled and outward. Eyebrows and eyelashes are light in color

Color of eyelids are consistent with skin complexion of face. Upper eyelids cover above iris. No evidence of ptosis or sty.

Inspect anterior structures of eyes

I will lightly pull down on your lower eyelid.

The conjunctiva is pink and moist, no conjunctivitis. The cornea is dome shaped, smooth, and transparent bilaterally. No signs of arcus senilis. The sclera is white. No signs of jaundice. The irises are round and brown and symmetrical bilaterally. No signs of coloboma.

Assess alignment of eyes

I will assess your corneal light reflex.

Please stare straight at the wall behind me.

I will shine the light in your eyes.

The light reflection is symmetric bilaterally and there is no asymmetric light reflection.

Test extraocular movements of CN 3, 4, and 6

I will test your eye movements by performing the 6 cardinal fields of gaze

Keep your head still and follow penlight with your eyes

The pt can parallel track all six fields. No nsytagmus.

CRANIAL NERVES 3, 4, AND 6 ARE INTACT

Test pupillary response - CN 3

I will test your pupillary response

First I will shine the penlight on your left eye

Pupil constricts to direct light

I will shine the penlight on your left eye again Right pupil constricts consensually

REPEAT FOR RIGHT EYE

Can you stare at the wall behind me and focus on my finger

Pupils dilate to distant object and constrict to close objects

No evidence of miosis or anisocoria

CN 3 and PERLA is intact

Inspect ears

Upon inspection of the ear, it is aligned with outer canthus of eye. No sign of cauliflower ear

There is no debris or edema upon assessing the ears

Palpate auricle AND mastoid area

I will palpate your auricles, then the tragus, and the mastoid area. Do you feel pain?

There is no pain and no evidence of lesions.

Assess hearing of CN 8

I will assess your hearing

I am going to stand 2 feet behind you and you must cover one ear and repeat the 2 syllable word I whisper.

Can you cover your left ear?

Repeat on other ear.

Pt is able to repeat the 2 syllable word. Negative result for whisper test, no unilateral hearing loss.

CRANIAL NERVE 8 IS INTACT

Perform otoscopic exam

To perform the otoscopic exam I will pull the pinna up and back. Does this hurt?

Upon inspection, the external ear canal is free of debris and edema.

Cerenum is yellow and waxy. There are no masses

The tympanic membrane is pearly gray and translucent. There is no bulging.

The cone of light shines at 5 o'clock (right ear)

Inspect external nose and septum

Upon inspection of the nose, it is symmetrical and at midline.

Can you tilt your head back? I will look inside your nose. Nares is symmetrical bilaterally. No signs of polyps or deviated septum

Can you breathe in and out through your nose? Nostrils are patent

Palpate nose

I will palpate your nose and sinuses. Do you feel any pain or tenderness?

Pt reports no tenderness and there are no masses felt

Inspect lips

Upon inspection of the lips, they are smooth, symmetrical vertically and horizontally, and pink with clear vermillion border. There is no cyanosis.

Inspect tonsils

Can you open your mouth for me?

The oral mucosa is pink and moist

Tonsils are +2 and symmetrical bilaterally

Inspect uvula

Can you say ahh? (with tongue blade)

Soft palate elevate and uvula retracts at midline

CRANIAL NERVE 10 IS INTACT

Assess tongue and ROM

Can you stick your tongue out? Can you move it towwards your nose, down to your chin, side to side?

Pt has full ROM of tongue

CRANIAL NERVE 12 IS INTACT

Assess ROM of neck

I will assess your ROM of your neck

Can you look up at the ceiling? Touch chin to your chest? Lay your ears on each shoulder? Rotate your head side to side

Did you feel pain? Pt has full active ROM without pain

Test CN 11

I will place my hand on your cheek and apply resistance. Can you turn your head against my hand? Other side

I will place my hands on your shoulders and apply resistance. Can you shrug your shoulders?

CRANIAL NERVE 11 IS INTACT

Inspect and Palpate nail

May I see your hands? Nail is smooth, intact, and pink. No evidence of cyanosis.

Nailbeds blanch with pressure and capillary refill is less than 2 seconds

Can you form a heart? Nail bed angle is less than 160 degrees with no evidence of clubbing

Assess skin turgor on back of hand

I will assess your skin turgor by pinching your hand

The skin is elastic and returns briskly. There is no tenting

Test ROM and strength

I will assess your ROM and strength.

Can you flex your elbows? Extend them?

Can you flex your elbows against resistance?

Can you extend your elbows against resistance?

Make a box with hands | |

Close box with wrist

Open and hyperextend

Make a box again and close with fingers

Extend fingers and spread them apart

Try to close them again with resistance

Can you make a fist and open it

Grab my hands and pull, now push

Squeeze my fingers.

Pt has 5/5 strength with equal grip bilaterally and full active ROM in the upper extremities

Assess radial pulses

I will assess your radial pulses for one minute

The pulse is __ bpm, regular, +2 symmetrical bilaterally

Test fine motor function and coordination

I will test your fine motor coordination.

Can you close your eyes and alternate between touching your fingers to your nose rapidly

Open your eyes, touch your nose, then touch my moving finger each time

Touch your fingers to your thumbs

Can you flip your hands over in your lap like this?

Cerebellar function is intact

Inspect skin and thorax

I will assess the thorax

AP to transverse ratio is 1:2

The skin is smooth, intact, and color is consistent with the rest of the body. No masses

Scapulae are symmetrical bilaterally with even muscle development. Ribs slope down about 45 degrees to spine

No sign of barrel chest

Auscultate symmetrically: posterior

I am going to listen to your lung sounds using the diaphragm of the stethoscope.

Please breathe in and out each time I move the stethoscope (10 points)

Can you cross your arms?

I hear vesicular at apex and bronchovesicular towards center and vesicular sounds as I move to the base

No adventitious breath sounds like wheezes and rhonchi are heard

Auscultate symmetrically: lateral

I will ausculate the breath sounds on the sides of your lungs (4 right and 3 left)

I hear bronchovesicular and vesicular breath sounds as I move towards the base of the lungs

No adventitious breath sounds such as crackles or stridor

Inspect anterior shape of thorax

Upon inspection of anterior thorax, it is elliptical and symmetric bilaterally

Costal angle is less than 90 degrees and chest expansion is symetrical bilaterally

No presence of emphysema

Inspect respirations

I will inspect respirations for one minute

Respirations are __ bpm and eupnic

Accessory muscles were not used

Auscultate symmetrically: anterior

I will auscultate breath sounds in the front (8 points)

I hear vesicular at apex, bronchovesicular towards center, and vesicular towards base of the lungs

There are no adventitious breath sounds such as crackles or rhonchi

Inspect cardiac landmarks

I will assess the precordium

Chest is round with no pulsations or bulging

Palpate PMI

At 5th ICS at left MCL, apical pulse is palpated

I am going to listen to your heart using the diaphragm of the stethoscope

At the Aortic Valve, 2nd ICS RSB, both sounds are heard, S2 is louder than S1

At the Pulmonary Valve, 2nd ICS LSB, both sounds are heard, S2 is louder than S1

At Erb's Point, 3rd ICS LSB, no murmurs are heard

At the Tricuspid Valve 4th ICS LSB, both sounds are heard, S1 is louder than S2

At the Mitral Valve 5th ICS LMCL, both sounds are heard, S1 is louder than S2

No splits were heard

Auscultate cardiac landmarks with bell of stethoscope

I am now going back over the same points with the bell of the stethoscope.

In AV/PV, no S3 is heard after S2

At Erb's Point no murmurs are heard

At TV/MV, no S4 is heard before S1

Inspect abdomen

I will assess your abdomen. Can you lay flat on the table please

Contour is flat, smooth, and color is consistent with the rest of the body

There is no peristalsis

Auscultate bowel sounds in 4 quadrants

I will auscultate the bowel sounds in 4 quadrants, starting with the right lower quadrant and listen for 5 seconds in each quadrant

I hear normoactive bowel sounds 5-30 in the RLQ

I hear normoactive bowel sounds in the RUQ

I hear normoactive bowel sounds in the LUQ

I hear normoactive bowel sounds in the LLQ

No hypoactive or hyperactive bowel sounds over 4 quadrants

Percuss 4 quadrants

13 pts

RUQ and LUQ dull

RLQ and LLQ tympanic

Palpate all 4 quadrants

I will palpate the abdomen over 4 quadrants

I will lightly palpate using my finger pads. Any pain or tenderness?

I will palpate deeper. Do you feel pain or tenderness?

No masses or lesions. Pt reports no pain or tenderness

Inspect skin of lower extremities

Upon inspection, the pt's legs are smooth and intact and color is consistent with rest of the body

There is no edema or varicose veins

Inspect toenails

Upon inspection, toenails are clean, pink, and smooth. No evidence of onychomycosis

Toenails blanch to pressure and capillary refill is less than 2 seconds

Palpate posterior tibial and dorsalis pedis pulses

I will assess your pulses

The dorsalis pedis pulses are regular, +1 symmetric bilaterally

The posterior tibial pulses are regular, +2 symmetric bilaterally

Test fine motor function and coordination of lower extremities

I will assess your lower extremities. Can you sit on the edge of the bed?

Can you rapidly tap your feet to the floor?

Can you run the heel of your foot down the shin of each leg?

Can you draw a finger 8

Pt has strong fine motor function and coordination of lower extremities

Cerebellar function is intact

There is no cerebellar impairment

Test deep tendon reflex (0 - +4)

I will assess the deep tendon reflex of the patella. Can you relax your leg?

Pt has a deep tendon reflex of +2. No hyperactive reflex

Inspect and palpate spine with client bending over

I will now assess your spine. Can you stand up please?

Can you bend over and touch your toes (palpate spine)

Can you stand up straight again?

Shoulders are parallel with the hips and perpendicular to the spine

Shoulder girdle is equal on both sides

Spine is aligned and there are no signs of scoliosis, kyphosis, or lordosis

Test ROM of spine

I will assess ROM of your spine. Can you lean back? Lean forward? Lean side to side? Rotate side to side? Do you feel pain?

Pt has full active ROM of the spine with no pain

Test proprioception and cerebellar function

Can you please walk across the room normally?

Pt has normal gait and arms swing in opposition. No sign of Parkinson's gait.

Can you walk back to me heel to toe?

Pt has a steady balance.

Can you close your eyes and stand on your foot while maintaining balance for 5 seconds? (support pt with your arms)

Now open your eyes, raise the same leg and hop in place.

Pt has full proprioception and cerebellar function is intact. There are no signs of Parkinson's disease.

Closing

Thank you, you can return to your bed.

Do you have any questions?

I will document my findings and report back to the physician.

Here is your call light if you need anything.

Open curtain

Hand hygiene (20 secs)

Pick up supplies and return to usual place (DO NOT LEAVE SUPPLIES AT BEDSIDE)