Head to Toe

Head to Toe Final Script

Introduction Statement

-       PPE

-       2 identifiers

-       Safety check

-       Instructions for pt.

General survey

  • Vital signs & Pain: within normal range, pt expressed no pain

  • While you’re here I will be feeling your radial pulses: both are normal and symmetrical.

  • I will also feel for your pulses in your feet okay? While we’re here, I’ll be checking capillary refill as well, you hand and your toes, no perfusion present- While I’m here I will be checking your skin as well- skin integrity is good.

  • Posture & Body Movements: good posture and no curve or scoliosis present and can move body freely.

  • Skin turgor: warm, dry no abnormal lesions, swelling and good skin turgor.

Neuro

-       What year is it?

-       Where are you?

-       Who is the president: good job, pt alert and oriented, GCS score 15. Speech clear and coherent no slurred.

-       Eyes: (CN 3, 4,6)

o   Go ahead and look up the ceiling and I will shine a light to check your pupils; pupil is both equal, round, reactive to light and accommodating.

o   H shape

o   Closer to your face

-       Facial movements (CN 7)

o   Smile?

o   Frown?

o   Puff out your cheeks?

o   Open mouth? : face is symmetrical and expressive with no drooping, CN 7 intact

-       CN 11

o   Shrug your shoulders up and down

o   Move your head against my hand: CN 11 intact

-       Bil

o   Go ahead and squeeze my fingers

o   Push away

o   Pull away

-       Drif

o   Close your eyes please, hold out your arm, palms up for about 10 seconds, feel sensation equally on both sides?

§  Push down

o   Same thing for your legs, feel sensation equally on both sides?

§  Push down, toes to your nose

-       Heel to shin

o   Lets do heal to shin for both legs.

-       Finger to nose

o   Switch index finger

-       During that time did you feel any pain? Okay so your extremity strength is 5/5, full strength and full range of motion

HEENT

-       Hand hygiene & gloves

-       Check nose: any discharge, bleeding. Touch for tenderness of septum deviation

-       Close one nostril and take a deep breath, no abnormalities

-       Check mouth, stick tongue: inspecting lips, cheeks, teeth, gums, throat: all normal

-       Check ears: outside for deformities, normal color and temperature

-       Feel for neck

o   Lymph nodes; no swelling, tenderness, or lumps

o   Move head side to side: tracheal deviation and swallow

o   Trachea symmetrical and normal

Cardiovascular & Pulmonary Assessment:

-       DIAPHRAGM: “I’m listening for any abnormal lung sounds such as crackles, stridor, rhonchi, or wheezing. But you had clear lung sounds in all lobes”

o   Deep breath 3x

o   Regular depth, rate, no kusmal, shallow breathing and normal chest rise. I’m also inspecting your scapula while I’m here.

o   While I’m here I’m looking at your skin integrity; warm, dry, non-diafranetic and no lesions, redness or swelling

-      BELL: “I’m also listening for your normal S1 and S2 heart sounds and listening for any abnormal heart sounds such as murmurs, friction rubs, or gallops.”

-       I’m also inspecting for thrills, okay good no thrills.

-       After listening, tell your patient that all their lung sounds and heart sounds were clear and normal.

Abdomen:

-       Inspect: not distended or discolored

-       Listen to your stomach: normal Bowel sounds; no hyperactive or hypoactive

-       I will be palpating

o   Palpating for tenderness, rebound, guarding, organomegaly

Bowel & Urination Q’s

-       Pee questions

o   Last time peed?

o   What it looks like

o   Pain?

-       Poo questions

o   Las time?

o   What does it look like?

o   Are you eating enough fiber?

Fishula & Drains: no

Gait:

-       Walk a few steps

Closing Statement

  • Let pt know of the results of the assessment: should be no abnormalities. Ask if they have any questions.

  • Report findings to pt, inform doctor and document findings.