Perform hand hygiene.

Check for safety and cautions in the room (360 degrees)

Adequate lighting
(I have a stethoscope and my penlight ready)
Hi my name is ____ and I'm going to be your nurse today.
I'm here to do your head to toe assessment. It will take me about 15 minutes to finish the whole
thing so do you need to go to the restroom first?
Yes
Okay so I'm going to assist him to the bathroom. I'm checking for his gait and making sure he's
steady and that he's got good balance. It's all great.
Okay mr. Hayes, is the lighting too bright for you? Is the room too cold?
no
Can you tell me your full name and date of birth?
Taylor Hayes 1/1/75
Do you have any allergies Mr. Hayes?
I'm allergic to iodine, Betadine, and KY lubricant.
Ok mr. hayes.  Can you tell me where you are right now?
I'm at Carrington Hospital.
Can you tell me why you're here?
because I have abdominal pain.
Can you tell me what year it is?
 it's 2021
(I'm wearing gloves)
Okay Mr. Hayes I'm literally going to start with your head and move all the way down to your
toes.  Stop me if you feel any pain, tenderness, or discomfort throughout my assessment.
So I'm starting from the patient's head and looking for any lumps, bumps, lesions, checking for
hair distribution of my patient.
Okay mr. Hayes have you had any Falls or trauma to your head?
no I haven't
Mr. Hayes can you push on my hands? Can you look up for me? Can you look down at your toes?
can you look to your left and your right? Okay looks good.
all right mr. Hayes I'm going to check for your Carotid pulse ( one at a time)
I'm checking my patient’s neck and throughout this I'm also checking skin integrity.
Mr. Hayes I'm going to take a look at your eyes. I'm going to shine a bright light on them. I want
you to look straight ahead. So I bring my penlight to both eyes
Okay mr. Hayes I'm going to have you follow my pen ( light off)  without moving your head.
So now I'm checking the patient's PERRLA (Pupils, Equal, Round, Reactive (to), Light,
Accomodation.)
So I'm checking the six fields of cardinal gaze
I'm going to have you follow my pen with your eyes only.  
Any drainage in your eyes mr. Hayes?
No
I'm checking if his conjunctiva looks red, if his sclera looks red. No drainage. 
Do you use any assistive devices for your eyes? Contact lenses glasses?
Yes, I use readers glasses.
I make sure they're available by the bedside.
Now I'm going to check my patients ears for any drainage, redness, tenderness, in the patient's ear
and then I'm going to go to the other side and check that ear.
Mr. Hayes do you have any problems recently with your hearing ability?
no I hear just fine.
 okay good.
 now I'm going to take a look at my patients nose. see if I see any drainage any redness, any
presents of tumors, or lesions, polyps or presence of nasal deviation on my patient.  I'm using my
pen light.
 mr. Hayes can you go ahead and take a deep breath for me through your nostril?  and then the
other one?
 do you notice any difference in passage of air through your nose?
No.  it seems normal
 I'm going to take a  look at my patients mouth
 Mr. Hayes use any dentures or partials
no these are all my real teeth
 okay mr. Hayes can you say ahh for me?
Uvula is midline I don't see any enlarged tonsils and don't notice any halitosis while I'm doing this.
 can you stick your tongue out for me
Ahhhhhh
 any problems with chewing or swallowing?
no everything's fine.
 all right that's good to hear.
 okay so I'm done with my ENT. I'm going to move down to my patients chest.  I'm going to check
for skin turgor on my patient's upper chest area. noting how long it takes for the skin to return to
normal.
okay mr. Hayes you look hydrated.
now I'm going to auscultate for my patients lung sounds and heart sounds
 okay mr. Hayes I'm going to listen for your heart and your lungs and your belly as well.
 I'm going to start with my heart sounds.  aortic pulmonic erb's point,  tricuspid, mitral
 everything sounds normal S1 and S2 noted
 I'm going to start auscultating for the lung sounds of my patient. I'm going to take a look where my
clavicle is.  
mr. Hayes every time you feel my stethoscope can you take a deep breath in and out for me?
1 2 3 4 5 6 7 8 9 10 
Mr. Hayes I'm going to have you sit forward for me. I'm going to listen for your lung sounds on
your back. And again, every time you feel my stethoscope can you take a deep breath in and out for
me?
1 2 3 4 5 6 7 8 9 10
While I do this I check  for the patient's bony prominences and pressure points on their back 
including their coccyx and sacral area. everything looks good. 
alright mr. Hayes your lungs sound clear to me.  I'm going to check your belly.  I'm going to lay
your bed flat so your abdominal muscles relax when I do my abdominal assessment. 
I'm going to auscultate first, then look, inspect. I'm going to start with the right lower quadrant
going to the right upper, left upper, left lower. I hear normal active bowel sounds.  
mr. Hayes I'm just going to feel for your belly.  let me know if there's any tenderness or discomfort.
do you have any nausea or vomiting? 
no I feel okay.
 when was the last time you had a bowel movement?
I had one this morning.
 can you describe the stool for me?  was it Brown soft or harder to pass?
no it was soft Brown easy to pass.
 okay good.  all right mr. Hayes I'm going to check for your pulses down here too ( brachial artery) 
and now I'm going to check the radial artery
 mr. Hayes can you try and squeeze my hands please?
 can you try to pull me close to you and can you try to stop me from pulling you?
 any numbness or tingling anywhere?
  No
 I'm checking for a capillary refill on every finger. they're all Less Than 3 seconds.
 mr. Hayes can you lift your arms up in front of you?  up and then to the side and then down?  can
you make a circle with your arm and then on your other arm?  Can you rotate your wrists for me? 
Mr. Hayes can I check your genitalia? I just want to make sure everything looks good down there?
oh sure.
Okay I'm checking my patients genitalia. I'm making sure I'm maintaining the client's privacy. 
Checking the tip of the penis.  
Any pain or discomfort? 
nothing.
 I checked the femoral pulses while I'm here.
 mr. Hayes any changes with your urination pattern? 
No
 how many times do you usually urinate a day?
3-4.
 before your assessment did you take note of your urine?
yeah it was light yellow,  a normal amount.
 mr. Hayes any pain while urinating?
No
 no funky odor to your urine?
no everything seems normal.
 Okay good. so mr. Hayes I'm just going to keep moving down to your lower extremities. 
(Fix blanket to expose legs)
 okay mr. Hayes I'm gonna feel for your pulses behind your knees.  any numbness or tingling in
your legs?
  Nope
Can you push down on my hands like you're pushing on a pedal?  can you pull your toes to your
nose?  can you lift your leg up for me?  lift your other leg up?  can you try and make a circle with
your leg?  and your other leg?  rotate your ankles? 

Now I'm going to feel for your dorsalis pedis pulses and posterior tibialis pulses. I'm going to check
your heels. looks good. 
Do you use any assistive devices at home Mr. Hayes?
  Nope i’m independent.
I checked capillary refill and they all come back within 3 seconds.
Any questions you have for me Mr. Hayes? 
No
I'm going to be back with your medications in about 20 minutes but if you need anything before
that,  go ahead and press your call light. (hand it to him) 
Okay I'm good for now but can you turn on my TV and fix my bedside table? 
Check for bed rails up
Bed in lowest position
Call light within reach
Bedside table within reach
“anything else I can get for you?”
“I will be back in about an hour to check on you Mr. Hayes. If you need anything don’t hesitate to
hit that call button.”