NR 304 Head to Toe Assesment Script

NR 304 Head to Toe Assesment Script

Student Name

Chamberlain University

NR-304: Health Assessment II

Prof. Name:

Date

Introduction

Upon entering the patient’s room, it is essential to initiate the encounter respectfully and safely. Start by knocking on the door, performing hand hygiene, and introducing oneself by name and role (e.g., “Hi, my name is Dana, and I’ll be your student nurse today”). Patient verification should follow, asking the individual to confirm their full name and date of birth. Provide privacy and explain the procedure: “Today, we will conduct a comprehensive head-to-toe health assessment, which typically takes 20 to 30 minutes and involves light physical contact and exposure. Is that acceptable to you?” Ask about any known allergies and assess current pain level on a scale from 0 (no pain) to 10 (worst pain imaginable). Adjust the bed to hip height and lower the side rail for comfort and safety.

General Appearance

Assess the patient’s general condition, noting the absence of acute distress. Observe for relaxed facial expressions, appropriate mood and affect, and clear speech. To evaluate orientation, ask the patient their name, location, time, and reason for the visit. A correct response indicates the patient is alert and oriented to person, place, time, and situation.

Skin and Nails

Inspect the skin for uniform color appropriate to ethnicity and check for any lesions or abnormalities. Palpate the upper and lower extremities bilaterally to assess temperature; it should feel warm and consistent throughout. Examine nails for color, curvature, and capillary refill, which should be under two seconds.

Head, Face, and Neck

Facial symmetry should be intact. The head should be normocephalic. After donning gloves, inspect and palpate the scalp, ensuring it is clean and free of lesions. Observe hair for even distribution and hydration. Assess the trachea for midline positioning and absence of masses. Evaluate cranial nerve V (Trigeminal) by testing motor function (jaw clenching) and sensory function (cotton ball touch). Assess cranial nerve VII (Facial) via expressions (smile, puff cheeks). Test cranial nerve XI (Spinal Accessory) by having the patient shrug shoulders and rotate the head against resistance.

Eyes

Inspect ocular structures for redness or discharge. Pull down the lower eyelid to examine conjunctiva (pink) and sclera (white). Assess pupil size (3 mm), symmetry, and reactivity to light. Test accommodation by having the patient follow a penlight toward the nose. Evaluate cranial nerves III (Oculomotor), IV (Trochlear), and VI (Abducens) by conducting the six cardinal fields of gaze. Absence of nystagmus confirms intact function.

Ears

Inspect the external ear for abnormalities or discharge. Perform the whispered voice test by standing approximately two feet away and whispering a series of letters and numbers, which the patient should repeat. This assesses cranial nerve VIII (Vestibulocochlear).

Nose

Inspect internal nasal structures for inflammation, asymmetry, or discharge. Evaluate patency by having the patient occlude one nostril and breathe through the other.

Mouth and Throat

Inspect lips, gums, and tongue, which should appear pink and moist. Assess cranial nerves IX (Glossopharyngeal) and X (Vagus) by observing uvula rise upon phonation and checking for effective swallowing and speech. Test cranial nerve XII (Hypoglossal) by asking the patient to say, “Light, tight, dynamite.”

Respiratory System

Inspect the chest for symmetry and effortless breathing. Auscultate anterior and posterior lung fields in a side-to-side pattern to detect any abnormal breath sounds. All lobes should present vesicular or bronchovesicular sounds, depending on location, without adventitious noises.

Cardiovascular and Peripheral Vascular

Palpate carotid, radial, dorsalis pedis, and posterior tibial pulses. Pulses should have a +2 force and a regular rhythm. Check for peripheral edema by pressing lightly on upper and lower extremities. Auscultate heart sounds over five main areas using both diaphragm and bell of the stethoscope:

No murmurs or irregularities should be heard.

Gastrointestinal and Urinary

Place the patient in a supine position. Inspect the abdomen for contour and symmetry. Auscultate bowel sounds in the RLQ, RUQ, LUQ, and LLQ. Then, lightly palpate all quadrants for tenderness, rigidity, or masses. The abdomen should be soft, non-tender, and without distension.

Musculoskeletal System

Inspect and palpate joints in both upper and lower extremities for symmetry, swelling, or deformities. Assess range of motion (ROM) and strength against resistance, grading each movement a 5 (normal). Evaluate elbows, wrists, knees, and ankles bilaterally. Test gross motor function and coordination by having the patient walk in a straight line.

Use a two-point discrimination test to check sensory integrity from proximal to distal.

Closure

Reassess pain level post-assessment using the 0–10 scale. Ensure the bed is in the lowest position, side rails are up, bed is locked, and the call bell is within reach. Ask if the patient has any final questions. Thank them for their cooperation and perform final hand hygiene.

References

Jarvis, C. (2020). Physical examination and health assessment (8th ed.). Saunders.

Bickley, L. S. (2020). Bates’ guide to physical examination and history taking (13th ed.). Wolters Kluwer.

NR 304 Head to Toe Assesment Script

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Seidel’s guide to physical examination: An interprofessional approach (9th ed.). Elsevier.