Head To Toes

Supplies

WASH HANDS. Pen Light, Tongue Blade, Sthetescope, Otoscope, Reflex Hammer, Glover, Hand Sanitizer

Introduction

*Knock* hi may I come in, my name is Tim and I’m going to be your nurse today. I’m going to be doing a head to toes assessment on you do you know what that is? Basically Its an assessment that involves me touching you and assessing your overall health status. Before I begin can I get your name and dob? Can I also see your wrist band please? Put on gloves and raise bed

Head and Face

Taking a look at their head and scalp I can see that it is normocephalic bilaterally symmetric and is midline to the body and perpendicular to their shoulders. I can see no evidence of micro or macrocephaly. Now I’m going to palpate your head, do you feel any pain or tenderness her x3. I feel no evidence of masses or lesions. Looking behind their ears I see no evidence of nits, lice, or tics.

Inspecting their hair I can see that it is evenly distributed with no signs of alopecia. I see that the hair is black, straight, and soft in texture.

Taking a look at their face I see that it is bilaterally symmetrical with no abnormal drooping on one side. I see that the skin color is consitent with the rest of the body with no evidence of involuntary movements like tics or tremors. Now I’ll test for your cranial nerve 7. Can you wrinkle your fore head, raise your eybrows, puff cheeks, smile w/teeth, smile w/o teeth, purse lips, whistle. Cranial nerve 7 intact.

Eyes

Taking a look at their their external structure of the eye I see that it is bilaterally symmetrical and the eylashes and eybrows are full with no evidence of balding. I see that the upper eyelids curve outwards and up and the lower eyelids curve inward and down. Having them close their eyes I see that the color is consistent with their body and their outer canthus aligns with the pinna of the ear. No evidence of edema, erythema, or masses

Inspecting their anterior eye structure when I pull down their lower eyelid I can see that the conjunctiva is pink and moist with no conjuctivitis, I see the sclera is white and clear with no evidence of jaunidce, Cornea is dome shaped and transparent bilaterally symmetric, and their iris is a deep brown color and round with no evidence of coloboma.

Assessing their alighnment Im going to do the corneal light reflex I’ll have you stare at the wall behind me while I shine this light in your eyes. I see that the light reflection is bilaterally symmetric with no signs of assymetric light reflections

Now I’ll be testing for your CN 3, 4, and 6 with the six cardinal fields of gaze. Follow my penlight with your eyes. Patient has no evidence of extreme nystagmus, CN 3, 4, and 6 intact

Lastly I’ll check for CN 3 by doing a direct and consensual light response test. Look at the wall behind me. I am shining the light in their right eye and I see that it constricts to 2mm and I shine it in their left eye and it constricts to 2mm. Moving on to consensual I see that their left eye constricts to 2mm when light is shined in their right eye and their right eye constrict to 2mm when light is shined into their left eye. CN3 Intact, pupils are round, equal, and react to light.

Ears

Taking a look at their ears I see that they’re bilaterally symmetrical and are aligned with the outer canthus of their eyes. Im going to palpate the auricle tragus and mastoid. Do you feel pain or tenderness x4. Patient has no pain or tenderness and no masses, lesions, or drainage on the outer ear.

Now I’ll test for CN 8 by doing the whisper test. I’m going to stand behind you and whisper a 2 syllable word which I want you to repeat. Cover your left ear; whisper popcorn, now cover your right ear; whisper apple. Patient CN 8 is intact with no unilateral hearing loss and were able to repeat the words back

I’ll be doing otoscope exam now so I will pull the ear up and back. Taking a look into the canal I see no evidence of masses or lesions, I see cerumen which is yellow, as I move deeper I see the tympanic membrane which is a pearly gray, translucent color with no perforation or bulging. I see the cone of light is 5oclock at the patients right ear.

Nose

On inspection of the nose it is bilaterally symmetrical and midline to the body. I’m going to have you look up. I can see that the nares are bilaterally symmetrical with no septum deviation, discharge, or perforation. You can look down now, I want you to close one nostril and breathe in, now do it for the other side. Nostrils are patent. I am now going to palpate your nose and sinus. Do you feel pain or tenderness x3. No evidence of masses or tenderness

Mouth and throat

Taking a look at their lips I see that its pinks with a defined border. No evidence of cyanosis, cracks, or lesions. I want you to open your mouth, I can see that the oral mucose is pink and moist with no signs of oral thrush. I see your tonsils are bilaterally symmetric at a +2 grade.

Testing for CN 10 can you say Ahh. I see the the soft palate and uvula retract and elevates at midline. CN 10 intact

Testing for CN 12, can you stick your tongue out, move it up, down, side to side. Patient has full ROM CN 10 intact.

Neck

Looking at their neck the color is consistent with the body, trachea is midline to the body and shoulders. Testing your ROM can you look up, down, touch your ears on each shoulder, and rotate side to side. Patient has full ROM.

Testing for CN 11. Im placing my hand on your right cheek can you turn against it. Now I’ll do it again on the opposite side. Now I’ll put resistance on your shoulder, can you shrug. CN 11 intact.

Upper Extremities

Can I see your nails. I see they’re smooth, intact, and pink. No evidence of pitting or beau lines. Now I’ll test your cap refill. When I apply pressure the nail beds blanch. I see that color returns within 2 seconds. Now can you form this diamond window. I see the nail bed is less than 160 with no evidence of clubbing.

Can you flip your hands for me. Testing your turgor I see that your skin is elastic and returns fast. No evidence of tenting.

Testing your ROM. Can you flex and extend your elbows, now we’ll do the same with resistance. Make a box. close-open-hyperextend with your wrist. We’ll do the same with your fingers, close-open-hyperextend-spread-shake. Can you push (hand to hand) can you pull (interlock finger and pull) can you squeeze my fingers. Patient has full ROM on upper extremities. Patient strength is 5/5 bilaterally symmetric with no signs of weakness.

Testing your fine motor function and coordination. Close your eyes and rapidly touch your nose with your fingers x4, You can open them now touch your nose with your finger then touch my finger x4, put your hands on your lap and flip them rapidly, lastly touch your fingers with your thumb. Patient has full control of fine motor funtion and coordination in upper extremites. They are bilaterally symmetric.

Now I’ll test your radial pulse. I feel that they are at a grade of +2 bilaterally symmetric and a bpm of 68. Your respirations are 16 BPM

Posterior Lungs, Back, and Lateral thorax.

Taking a look at their posterior thorax from the side I can see the transverse AP ratio is 1:2 with no evidence of barrel chest or pectus excavatum with no masses or lesions.

Now I’m going to auscultate. I’ll have you cross your arms. Every time you feel the diaphragm of the stethescope I want you to take a deep breath. I hear no evidence of adventitious breath sounds such as wheezing, or rhonci, As I get closer to the base of the lungs I hear only bronchovesicular and vesicular sounds.

Keep your hands in that position I’m now going to listen to the lateral lungs. 4 points on left, 3 on right. I hear no adventitious breath sounds such as rhonci or wheezing and as I get close to the base I hear only vesicular sounds

Anterior lungs

On inspection I see that the rib cage slopes at a 45 degree, skin color is consistent, and no evidence of masses or lesions.

Auscultating the front 12x I hear no adventitious breathing such as rhonci or wheezing I see no evidence of any accessory muscles being used to breath, only bronchovesicular and vesicular noises heard.

Anterior Thorax

Looking at the precordium I see no masses or bulging. Testing for heaves or thrills place back hand on chest. I feel no evidence for them, lastly I’ll palpate the PMI, and I feel a light tapping rhythm with no bounding rhythm.

I’m going to listen to your heart with the diaphragm of the stethescope. Starting at aortic vale 2nd intercostal right sternal border I hear s2 is greater than s1, Pulmonary valve at 2 ICS LSB I hear s2 is greater than s1, Erbs point 3rd ICS LSB I hear no evidence of murmurs, Tricuspid valve at 4th ICS LSB I hear s1 greater than s2, lastly Mitral valve 5th ICS LSB I hear s1 greater than s2.

No I’m going to auscultate with the bell. At the tricuspid and mitral valve I hear no s4 before s1, at erbs point I hear no systolic/dystolic murmurs, and the Aortic and pulmonary valve I hear no s3 after s2.

Abdomen

Im going to have you lay on the bed on inspection I see skin color is consistent, stomach is flat, no evidence of peristalis, or venous patterns.

I’m going to auscultate for your bowel sound starting at the RLQ. I hear that all 4 quadrants are normoactive and free of hyper and hypo active sounds. I hear 1 bowel sounds every 5 seconds.

Now I’m going to percuss. take gloves off. If you feel any pain or tenderness just let me know. Okay so no pain or tenderness observed in all 4 quadrant. Tympanic sounds are heard in all quadrants except for the RUQ because of the liver

Now I’m going to palpate starting with light. Do you feel pain or tenderness x4. Now I’ll do deep palpation. Do you feel pain or tenderness x4. No pain or tenderness upon palpation. No masses or lesions present.

Lower extremities Pt. 1

Looking at my patients legs I see the skin is smooth and intact with no evidence of edema or engorged veins.

Looking at their toes nails I see that they’re intact, pink, and smooth. No evidence of pitting. Testing for their cap refill. I see the toe nails blanch upon pressure and color returns within 2 seconds. Now I’ll asses your dorsalis pedis and posterior tibial pulse. Your dorsalis pedis pulse has a grade of +2 bilaterally symmetric and the posterior tibial is a +1 bilaterally symmetric.

Lower Extremities Pt 2

I’ll have you sit at the edge pf the bed and I’ll test your fine motor function. Can you rapidly tap your feet in the air, perform a figure 8 with each leg, run each heel down the opposite shin. Patient fine motor function and coordination intact

Now I’ll test your deep tendon reflex. Relax your leg. Patient has a reflex of +2. No evidence of hyperactive reflex.

Neural System and Spin

Now I’m going to lower the bed. Can you stand up please. Looking at their shoulders they are parallel to the hips, shoulder girdle is equal on both side. Can you bend foreward. Im going to palpate. Do you feel pain or tender x4. Patient has no pain or tenderness. You can now stand up straight again. I see that the spine is aligned with no evidence of kyphosis or scoliosis.

Testing the ROM of your spine can you bend back, bend foreward, side ways, and rotate. Patient has full ROM of spine with no pain.

Testing your proprioreception and cerebellar function. Can you take 5 steps foreward. On the way back can you walk heel to toe. Can you close your eyes and balance on one leg. Now on the opposite side. You can open your eyes and can you hop in place on one leg then the other. Patients proprioreception and cerebellar function is intact. Patient is able to remain steady and balanced. Proprioreception and cerebellar functions are intact.

Closing

Thank you, you may sit on your bed. We’re finished with your head to toe, so now I’ll document my findings and report to the doctor. Bed is lowered, I’ll raise the siderails, your call lights there, open privacy curtain, hand hygiene for 20 seconds, clean supplies, questions?, leave.