head to toe check off

Step 1

Hi Im mia im going to be your nurse today and we will be doing a head to toe assessment. (wash hands) can you tell me your name and date of birth… perfect can you spell your last name. Okay and do you have any allergies or reactions

Step 2

patients appears clean, and appropriate dressed for the wheater. Ok and can you walk around the room a little bit, okay perfect patients gait is coordinated and symmetrical. Okay and do you know where you are, what year it is, and who you are. Ok patient is alert and orienated times 3.

step 3

now ill be doing your vital signs

• temp: lift up tongue do not bite down

• pulse

• respiration

• BP: ask about normal Bp rate

• apical pulse

• O2 sat

• pain on a scale of 0-10

step 4

okay and can you open our mouth for me? okay oral mucosa is mosit, pink, and intact, teeth are intact and no lesions in patients mouth. Okay now i will be looking in your eyes with a penlight ok pupils are equal round, reactive to light and accomdation. sclera is white and cornea is smooth and clear.

step 5

okay now i will be doing a respiratory assessment. patient is sitting upright and relax and is not sitting in tripod positiion. Patients skin lip and nail color are appropriate for ethnicity. breathing is even and effortless with even chest expansion. Ap to lateral diameter in 1:2

step 6

alright now i will be listening to your breath sounds I will be listening on your skin and please take big breaths through an open mouth ok. I will be listening to 6 sites in the front… Alright spots one and two were bronchovesticula where inspiration and expiration were equal and spots 3-6 were vesticular with long inspiration short expiration

step 7

alright now i will be listening to 8 spots on your back same thing breath through an open mouth… alright spots 1-4 were bronchovesticular where inspiration and expiration was equal and spots 5-8 where vesticular with a long inspiration and short expiration and soft breezy lung sounds. both anterior and posterior lung sounds were clear bilaterally and if i were listening to bronchial breath sounds I would hear them over the trachea with a short inspiration long expiration

step 8

alright now we will be moving on to a cardiac assessment and i will be listening to your heart

• first i am going to listen to the aortic valve and the 2nd ics RSB S2 is greater than S1

• then I will listen to your pulmonic valve at your 2nd ics LSB where S2 is grater than S1

• now I will listen to your erbs point at 3rd ics LSB where S2 and S1 are equal

• then i will listen to your tricuspid valve at 4th ics LSB where S1 is Greater than S2

• Finally i will be listening to your mitral valve at the 5th ics lmcl where S1 is greater than S2

no murmurs or extra neart sounds where heard

step 9

alright now I am going to plapate your carotid artery realy quick imma have you look that way (then palpate carotid on opp side) now look this way (palpate other carotid) alright pulses are symetrical and not jugula vein disrention noted.

step 10

now I will be moving on to you abdominal assessment. when was your last bowel movement? ok and have you had any bowel difficulites nausea vomiting, constipation, diarrhea? and and was your last stool brown and soft? perfect. have you had any urinary difficulty? burning frequency pain blood in urine? and your urine is light yellow and clear? alright

Step 11

okay now I am going to start your abdominal assessment. Patients skin is smooth, undertones are appropriate for ethnicity, and no striae or scares noted no peristalsis or epigastric pulse noted. patients abdomen is flat when patient is lying down and abdominal muscles are symmetrical and umbilicus is centrally located.

step 12

now i am going to listen to your bowel sounds… alright normoactive bowel sounds ausculated in all 4 quadrants. now i will be palapting your stomach and bladder… no tenderness masses or buldges in abdomen and umbillicus and not distention or tenderness when palpating the bladder.

step 13

okay now i will be looking at your upper extremities. patients upper extremities are appropriate color for ethnicity, hair distribution is even and there extremities are warm towards the core and get cooler distally, skin is dry.

step 14

ok now i am going to have you lift your arms like this and like this alright patients muscle movements are symmetrical and movements are coordinated. Now i am going to do capilarly refill… alright capillary refill is less than 2 seconds. Now i am going to palpate your skin turgor and not tenting is noted. now i am going to have you sqeeze my fingers… alright muscle strength is 5+ bilaterally. alright now i am going to grade your pulses… brachial and radial pulses graded 2+.

step 15

okay now i am going to be examining your lower extremities. patients lower extremities are appropriate color for ethnicity, and have you shaved recently? hair follicle distribution is even. okay now i am going to have you lift your legs like this and then like this… alright muscle are symmetrical and movements are coordinated.

step 16

ok and there extremities are warm towards the core and get cooler distally, skin is dry and intact. Now i am going to do capilarly refill… alright capillary refill is less than 2 seconds. now I am going to grade your dorsalis pedis and posterior tibial pulses… pulses are graded 2+ bilaterally.

step 17

ok now I am going to have you push down on my hands while i push up… and now you are going to pull your toes up while i push down on your feet… alright plantar flexion and dorsi flexion is 5+ bilaterally

step 18

alright I am now going to palpate you feet, ankles and shins for edema… no edema noted bilaterally.

step 19

okay I am going to share my findings with the provider and we will be back in (wash hands)