Head to Toe Assessment

I will start with hand hygiene

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Now I will introduce myself

My name is Mallory, I’m a student nurse and I’m gonna be doing your head to toe assessment today

I am going to confirm my patient’s identification

(While looking at their wristband) Can you tell me your name and date of birth?

Now I will provide privacy

(Pulls curtain)

I am going to now start the general survey by assessing the patient’s physical appearance

She appears to be her stated age, she seems alert and oriented, and there are no signs of acute distress

Now I am going to assess the patient’s body structure

Her height and weight appears normal for her age and her posture is erect

Now I will assess the patient’s mobility

When she walked in, her gait was smooth, coordinated, and there was no evidence of involuntary movement

I will now assess the patient’s behavior

She is making eye contact with me, and has proper facial expressions, clear speech, and proper hygiene and grooming

I will now assess for pain

Are you experiencing any pain today? If so, rate it on a scale of 0-10, with 0 being no pain and 10 being the worst

I will now assess mental status, including orientation, level of consciousness, and memory

Can you tell me your name and date of birth again?

Can you tell me where you are?

Can you tell me what time it is?

Can you tell me what you had for dinner last night?

Patient is alert, oriented to person, place, time, and short term memory is intact