Head-to-Toe Assessment Script PDF

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Assessment ...

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Instructor • Pull Curtain for privacy & Wash Hands!

! Patient •“Hello my name is Stefani and I will be your student nurse today. I will be doing your physical assessment and vitals. Is now a good time?! • “ I am going to raise the head of your bed is that ok?”!

Instructor! •“ I have established my pts level of consciousness and she is alert and oriented x3! ! Patient! • “ Now I will take your blood pressure using the 2 step method”! Instructor! •I will inflate the cuff until I can no longer feel a radial pulse then inflate 30 mm/Hg above that number! $ $ Note: Her Blood Pressure is XXX/XX ! Patient! “ Mrs.__ I will now asses your pulse”! Instructor!

‣ I will count her respiration’s for 60 seconds! ! Patient ! TURN LIGHT OFF! •“ I am going to turn the light off and assess your pupils with my pen light, please just look at my nose. Now please follow my pen with your eyes”! Instructor! • Pts pupils are equal, round, reactive, and accommodating to light! ! Patient (TURN LIGHT BACK ON)! • “Can you please open your mouth, stick out your tongue and say ahh”! • “ I am assessing for moisture/hydration and color of mucous membranes ! Instructor ! • Pts mucous membranes are moist and pink! ! Patient! •“Now I am going to asses your skin for color, temperature, and moisture. Can you please hold your arms out”! Instructor! • her skin is warm, pink, dry! • No sign of elbow skin breakdown! • Both Radial pulses are +3 in amplitude/equal bilaterally ! • Cap-refill is under 3 seconds! • Skin turgor is elastic and non tenting ! • PT has 2 tattoos on left arm and minimal scaring ! ! ! ! ! !

Patient! •“Can you please squeeze my 2 fingers with all your strength? Now don’t let me pull you. Now push against my hands”! Instructor ! • Upper extremity grips/pulls are strong/equal! ! ! ! Patient! •“ I am going to listen to your posterior lung sounds. Can you please lean forward and take a deep breath every time I place my stethoscope on you?! Instructor ! • 1-2 = Bronchovesticular! • 3-4 = Vesticular! • 5-6 = Vesticular!

Patient! • “I am going to check your sacrum for any edema/breakdown”! Instructor! • There is no evidence of edema or breakdown! ! Patient! •“Can you please lean back. I am going assess your anterior lung sounds. Can I lower the head of your bed?”! Instructor ! • 1-2 = Bronchovesticular! • 3-4 = Vesticular! • 5-6 = Vesticular ! • 7-8 = Lateral Vesticular!

Patient ! • “ I am going to asses your heart now”! Instructor ! • I will listen to S2 in the aortic region @ the right 2nd intercostal space! Patient! • “Can you please lift your breast so I can listen?”! Instructor ! •I will listen to S1/Apical pulse @ the left 5th intercostal space, midclavicular line!

Patient! • “I am now going to inspect your abdomen”! Instructor! • I am going to inspect for shape, scaring, and pulsations !

Patient! • “I will now listen to your stomach. Do you mind if i lift your shirt up?”! Instructor! •I will listen for bowel sounds in all 4 quadrants, starting in the RLQ, 2-3 minutes in a clockwise direction!

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Patient! •“Now I am going to palpate your stomach. Please let me know if you feel any pain/discomfort”! • “When was your last bowel movement?”! • “Do you experience any discomfort while urinating?”! Instructor ! • (In a circular motion) Abdomen is soft & non-tender! ! ! Patient! •“ I am going to asses your legs/feet for color, temperature, moisture and any presence of edema in legs as well as breakdown of the heels”! Instructor ! • Skin color is warm, pink, dry! • No evidence of pitting edema (shin) or breakdown in heel! • Cap-Refill is less than 3 seconds! • Pedal pulses are +3 and equal bilateral ! • Pt has a tattoo on lower left ankle! ! Patient! •“ Can you please push down on my hands like a gas pedal? Can you pull your toes toward your face?”! Instructor ! • Pulls/pushes are strong, equal and bilateral ! ! Patient! •“ Okay Mrs. ___, this completes my assessment. Do you have any questions/concerns? Are you comfortable? Do you need anything at this time?!...