Head to Toe Script

• I’m going to shut the for privacy and wash my hands

• Hi my name is Mikaila and I’ll be your student nurse today

• Can you tell me your name and date of birth; can I see your wristband?

• Today I am going to be doing a head-to-toe assessment 

• Can you tell me where you are? What month it is? Patient is alert and oriented x4 with speech being clear and coherent

intro

• patient is a 19yo female

• there are no signs of acute distress or obvious physical deformities

• patient appears to be well nourished with skin color matching race and ethnicity 

• can you please smile? facial features are symmetrical with mood and facial expressions calm and composed 

• patient is sitting in an upright position, erect posture, medium stature, no drooping to either side with body alignment appearing symmetrical 

• personal hygiene is adequate and patient is dressed appropriately for setting

• i’m going to look at your vital signs. your vital signs are within defined limits

• are you experiencing any pain or discomfort? where is the pain located? when did it start? what makes it better or worse? how would you describe the pain shooting, stabbing, throbbing? does the pain radiate to anywhere? how would you rate the pain on a scale of 1 to 10? does this pain affect your daily living? 

• I see no visible IVs or catheters bags. I don’t see any AV fistulas or dressings. Do you use any oxygen supplementation, nasal cannulas? 

general appearance, vital signs, pain

• I am going to start the assessment, can I touch you?

• ears are symmetrical, no discharge or swelling, temperature is warm

• I’m going to feel your periorbital area. no swelling is felt. any pain or tenderness?

• sclera is pearly white. eyelids are symmetric and close completely 

• I am going to look at your eyes, if you could look beyond my shoulder. pupils are equal, round, reactive to light and accommodation; consensual light reflex is intact and light reflects at the same point

• can you open you mouth and say “ah”. oral mucosa is pink, moist, and there are no wounds or lesions. can you look up for me and swallow? any difficulty swallowing, pain or tenderness? have you had a recent cough or sputum? trachea is midline

• I’m going to take a cotton swab and touch different areas, can you please tell me where I am touching? fine point localization and light touch are intact

head

• palpate upper arms. muscle tone is symmetric bilaterally with no signs of atrophy

• hair is distributed evenly on both arms

• there is no edema, 0/5

• temperature is warm

• no scars or lesions are present 

• capillary refill is less than 3 seconds

• radial pulses are 2+ bilaterally and symmetric 

• muscle strength is 5/5 bilaterally

upper extremities

• patient shows no accessory muscle use or nasal flaring. no cyanosis and patient appears comfortable and relaxed

• AP ratio is 1:2 and no barrel chesting 

• I’m going to listen to breath sounds at 1,3,5; lung sounds are clear and equal bilaterally with no adventitious lung sounds 

• I’m going to listen to erb’s point for 15 seconds at 3th ICS; s1 and s2 are equal and present

• I’m going to listen to breath sounds at 2,4,6,9 and right middle lobe at 4th ICS; lung sounds are clear and equal bilaterally with no adventitious lung sounds

chest

• skin is appropriate for race and ethnicity 

• there are no scars, lesions, or wounds

• umbilicus is midline and rounded

• no pulsations or bulging

• contour appears to be flat, abdomen appears symmetric

• listen to bowel sounds starting in RLQ; all quandrents are normoactive

• palpate all quadrants; any pain or tenderness? I did not feel swelling or lumps. abdomen was soft

• when was your last bowel movement? was it small medium or large? was it formed, solid, watery? what was the color? was it painful?

• when was the last time you urinated? what it small, medium, or large? was it cloudy or clear? what color was it? do you have any pain? 

abdominal

• palplate legs

• muscle tone is symmetric and hair is distributed equal bilaterally 

• skin is warm and color is appropriate for race and ethnicity 

• no scars, lesions, or wounds

• no pretibial or pedal edema

• capillary refill less than 3 seconds

• posterior tibial pulse and pedal pulse are 2+ bilaterally 

• muscle strength is 5/5 bilaterally 

lower extremity

• can you please walk to the door and back

• gait is steady and smooth, no swaying 

• i am going to assess your bony prominences. I am going to look at the occiput, scapulas, elbows, sacrum, ischial tuberosities, trochanters. do you have any tenderness? no redness or skin breakdown

• recap

gait and bony prominences