head to toes

Introduction

HI my name is Zuly and I will be your nurse today. We will be completing your head to toe assessment which should take about 30 minutes.

Identification and allergies

Can you please tell me your full name and DOB?

Any allergies to food, medications or latex, iodine or tape?

Safety

Im going to lock your bed, raise your bed rails, make sure your bed is low.

I can see that you dont have any IV LINES, Arm sites or pumps.

Based on your medical chart you are room air and don’t require oxygen and no cathers are being used is that correct?

Raise the bed

I am going to raise the bed to a comfortable working position.

LOC AND SPEECH

Can you tell me where you are?

Can you tell me todays date?

What brought you in today?

You previously stated your name and based on these answers I can tell your oriented x4 with clear and articulate speech.

On a scale of 0-10

0 being no pain and 10 being the worst pain imaginable, what do you rate your pain today?

Is that an acceptable amount of pain for you?

Now I am going to get your vitals signs.

BP

HR

R

TEMP

SATURATION

Eyes

Can you look straight ahead at me while I check your eyes?

Your pupils are equal and round at 4mm and they constrict to 2mm with light. Direct and consensual light reflexes are present.

Facial nerves

Now I’m going to assess your facial nerve, also known as cranial nerve VII. Please smile and show me your teeth. Now frown. Raise your eyebrows. Close your eyes tightly and don’t let me open them. Puff out your cheeks. Great, your facial expressions are intact and symmetrical bilaterally.

Mouth

Now I’m going to inspect the inside of your mouth. I do not see any sores, loose teeth, or signs of infection. The mouth is pink and moist with no lesions.

Respiratory

Any shortness of breath at rest or with activity?

AP diameter is less than transverse, respirations are even and unlabored with no accessory muscle use.

I am now going to listen to your lungs using the bell of my stethoscope.

(Listens)

Breath sounds are clear bilaterally. No adventitious sounds noted.Resonance throughout.

Cardiovascular

Inspecting precordium: no pulsations, heaves, or lifts noted.

Auscultating with the diaphragm:
Aortic, second right intercostal space.
Pulmonic, second left intercostal space.
Tricuspid, left lower sternal border.
Mitral, fifth left intercostal space at the midclavicular line.

Heart rate and rhythm are regular. S1 and S2 are present.

Now auscultating the same four areas with the bell.
No S3, S4, or murmurs noted.”

Gastrointestinal

Any change in weight, appetite, nausea, vomiting, or bowel movements?

Any urinary changes such as color, pain, odor, hesitancy, frequency, or incontinence?

Abdomen is flat, symmetrical, and umbilicus is midline.

Bowel sounds are present and normoactive in all four quadrants.

No aortic bruit noted.

Abdomen is tympanic to percussion.

Abdomen is soft and nontender.

Jvd