Patient Assessment Script p1 & p2

What is the very first thing you do?

Knock knock.

What do you say immediately after knocking?

Hi, my name is _____. I'll be your nurse today.

What do you say after introducing yourself?

I'm going to wash my hands and close the door for your privacy before we start.

What do you do for privacy and hand hygiene?

Wash your hands and close the door.

What do you ask after hand hygiene and privacy?

Can you tell me your first and last name and your DOB?

What must you check after asking for name and DOB?

The patient's wristband.

What do you ask after checking the wristband?

Do you have any allergies to any medications?

If they have an allergy, what do you ask?

If so, what type of reaction do you have?

What do you ask after the allergy question?

Do you have any pain anywhere?

What comes after the pain question?

Cognitive assessment.

How do you introduce the cognitive assessment?

I just have a few more questions to ask you.

What is the first cognitive question?

Please state your full name for me.

What is the second cognitive question?

Can you tell me where you are?

What is the third cognitive question?

Can you tell me what year it is?

What is the fourth cognitive question?

Can you tell me who the current U.S. president is?

What is the fifth cognitive question?

Can you tell me what brings you here today?

What comes after the cognitive questions?

Explain the head-to-toe assessment.

What does the head-to-toe assessment include?

Inspecting your extremities and certain areas of your body.

What do you do after inspecting?

Palpate, which is to feel for tenderness in certain areas.

What else do you check during the assessment?

Fingernails and skin elasticity.

How do you assess skin elasticity?

Gently pinch and lift the skin.

What do you say about explaining the assessment?

As we go through the assessment, I'll explain everything further.

What comes after explaining the assessment?

Take the patient's vital signs.

What vital signs do you specifically check?

Blood pressure and oxygen level.

What is the exact vital-sign transition?

I am now going to take your vital signs. I will be checking your blood pressure and oxygen level.

What begins Part 2?

Inspect and palpate the upper extremities.

What are the upper extremities listed?

Shoulders, elbows, hands, and fingers.

What do you check during the upper-extremity assessment?

Temperature, texture, tenderness, swelling, skin lesions, and radial pulse.

What comes first in Part 2?

Upper-extremity visual inspection.

Which areas do you visually inspect?

Shoulders, arms, elbows, forearms, wrists, hands, and fingers.

What do you look for during visual inspection?

Skin color, uniformity, lesions, scars, birthmarks, and localized swelling/edema.

What comes after visual inspection?

Temperature and texture assessment by palpation.

How do you assess temperature?

Gently touch from the shoulders down to the fingertips.

What are you checking for with temperature?

Warmth or coolness, comparing left and right sides.

How do you assess texture?

Lightly stroke the skin down the extremities.

What textures are you checking for?

Smoothness, dryness, moisture, or roughness.

What comes after temperature and texture?

Tenderness and swelling check by palpation.

What do you palpate at the shoulders?

Clavicles, acromioclavicular (AC) joints, and shoulders.

What do you ask while palpating the shoulders?

Ask the patient to report any pain or discomfort.

What comes after the shoulders?

Palpate the elbows.

What parts of the elbows do you palpate?

Inner and outer elbow and olecranon process.

What is the olecranon process?

The bony tip of the elbow.

What do you check for at the elbows?

Tenderness, nodules, or fluid effusion.

What comes after the elbows?

Palpate the hands and fingers.

Which joints do you palpate on the hands?

MCP and PIP/DIP joints of both hands.

What does MCP stand for?

Metacarpophalangeal.

What does PIP stand for?

Proximal interphalangeal.

What does DIP stand for?

Distal interphalangeal.

What do you check for at the hand and finger joints?

Swelling, localized heat, and tenderness.

What comes after hands and fingers?

Bilateral radial pulse assessment.

Where do you place your fingers for the radial pulse?

On the flexor aspect of the wrist, thumb-side, over the radial artery.

Which fingers do you use?

The pads of your index and middle fingers.

How do you position your hands for the radial pulse?

On both wrists simultaneously.

What do you do after positioning your fingers?

Lightly compress the radial arteries to feel the pulse.

What do you assess in the radial pulse?

Rate, rhythm, and pulse strength/amplitude.

How do you assess the two radial pulses?

Compare both sides bilaterally.

What is an example of normal pulse strength?

2+ normal, equal bilaterally.

What is the complete Part 1 order?

Knock → introduce → hands/privacy → name/DOB → wristband → allergies → reaction → pain → cognition → assessment explanation → vitals.

What is the complete cognitive order?

Full name → location → year → current U.S. president → what brings you here.

What is the complete Part 2 order?

Upper extremities → inspect → temperature → texture → shoulders → elbows → hands/fingers → radial pulse.

What is the visual inspection order?

Shoulders → arms → elbows → forearms → wrists → hands → fingers.

What is the palpation order?

Temperature → texture → shoulders → elbows → hands/fingers.

What is the radial pulse order?

Index/middle fingers → both wrists → lightly compress → rate/rhythm/strength → compare bilaterally.

What are the four big sections of Part 1?

Introduction → patient information → cognitive assessment → assessment/vitals.

What are the four big sections of Part 2?

Inspection → temperature/texture → tenderness/swelling → radial pulse.

What should you remember before starting the script?

Knock, introduce yourself, wash hands, and provide privacy.

What should you remember after patient identification?

Allergies → reaction → pain → cognitive assessment.

What should you remember after cognitive assessment?

Explain head-to-toe → palpation/skin → vital signs.

What should you remember after starting Part 2?

Inspect first, then palpate.

What should you remember after inspecting?

Temperature → texture → tenderness/swelling.

What should you remember after shoulders?

Elbows → hands/fingers → radial pulse.