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Assessment Head To Toe Script
Assessment Head To Toe Script
Introduction
I would like to do a physical assessment and ask you a few questions. Is not a good time?
Good, I am going to provide us with some privacy. (pull curtain)
Take temp. Put cuff on one arm, pulse ox on the other and run machine while checking radial pulse and respirations.
Patients blood pressure is ___/___ on her right arm in the supine position.
Radial pulse is ____, regular rate and rhythm.
Oxygen saturation is ___% on room air.
Respirations are ____ breaths per minute with regular rate and rhythm, non-labored.
Oral temperature is ___F.
Are you having any pain today?
Integument
Inspect skin for color, temp, moisture and texture; head, both arms and both legs with back of hands.
Skin color is appropriate to race.
No obvious elevations in temperature noted.
Skin is dry, warm and smooth.
No skin lesions observed
No tenting observed.
Actions Questions to Patient Report of Findings
Chest/Lungs
Are you having any shortness or breath or cough?
Inspect chest for symmetry of movement and assess respiratory movement.
Respiratory pattern is regular and symmetrical.
Effort appears to be non-labored with no obvious retractions or use of accessory muscles.
Auscultate anterior right and left breath sounds - 2nd intercostal space, mid-clavicular line, left and right
Auscultate lateral breath sounds at 5th intercostal space anterior to mid-axillary line - where the breast starts (in line with nipple)
Auscultate posterior right and left breath sounds in a butterfly pattern, snake back and forth - 6 locations starting above clavicle
There are no obvious wheezes, rhonchi, crackels, rubs or stridor, bilaterally
Heart
Are you having any chest pains?
Do you feel like your heart is pounding or beating irregularly?
Auscultate apical pulse at apex, 5th intercostal space, can be over breast tissue - nipple - diaphragm and bell
Apical pulse has regular rate and rhythm with no obvious murmurs, gallops or rubs
Check capillary refill on both hands and feet
Capillary refill is less than 2 seconds
Actions Questions to Patient Report of Findings
Abdomen
Are you having any nausea, vomiting, diarrhea, constipation or problems with urination?
Can you please bend your knees for me? I am going to press on your stomach a bit, let me know if you feel any
tenderness or pain.
Palpate abdomen lightly in a circular motion with fingertips, hitting all 4 quadrants
No tenderness or rigidity noted with light palpation
Palpate abdomen deeply with one hand on the other, hitting all 4 quadrants
No tenderness, organomegaly or masses noted with deep palpations
Neuromuscular/Peripheral Vascular
Are you having any numbness or tingling?
Are you having any calf pain?
There are no IV sites or pumps, no medical equipment, no incisions or wounds present, and no apparent
drains or TED hose.
Focused Cardiovascular
Can you tell me your name again please?
Do you know where you are right now?
Do you know what day of the week it is?
Patient is A&O x3, oriented to person, place and time
I need to take your vital signs
Instructor will say “vital signs have been taken”
Assess color and capillary refill of index finger and big toe bilaterally
Capillary refill in extremities is less than 2 seconds bilaterally
Focused Respiratory
Can you tell me your name again please?
Do you know where you are right now?
Do you know what day of the week it is?
Patient is A&O x3, oriented to person, place and time
Assess sputum
There is ____ amount of sputum that is ____(thick, watery, frothy) and ___in color
Inspect skin and lips for color
Skin and lips are pink, no erythema or cyanosis noted
Inspect trachea for midline placement
Trachea is midline
Inspect chest for symmetry of movement and configuration
Symmetrical movement of chest with no abnormalities of configuration
Assess respiratory effort
No obvious retractions or use of accessory muscles
Auscultate anterior right and left breath sounds in 8 locations starting above the clavicle in a butterfly pattern and snake back and
forth
Auscultate lateral breath sounds in 4 locations on each side starting in anterior armpit, 2nd intercostal, 4th intercostal and 5th
intercostal, moving anterior for right side for middle lobe
Auscultate posterior right and left breath sounds in 10 locations starting above clavicular line, using a butterfly pattern and snake
back and forth
Breath sounds are symmetrical with no obvious signs of wheezes, ronchi, crackles, rubs or stridor
Percuss lung fields for dullness in 10 posterior locations, same as auscultation locations
No obvious areas of dullness
Auscultate heart sound at the apex, 5th intercostal mid-clavicular line; nipple area with bell and diaphragm
Heart rate and rhythm are regular with murmurs, gallops or rubs
Inspect fingers for clubbing
No clubbing observed
Actions Questions to Patient Report of Findings
Focused Neuro
Can you tell me your name again please?
Do you know where you are right now?
Do you know what day of the week it is?
Patient is A&O x3, oriented to person, place and time