Head to Toe Assessment Transcript Nursing, Cheat Sheet for Nursing, Exams of Nursing

Download Head to Toe Assessment Transcript Nursing, Cheat Sheet for Nursing and more Exams Nursing in PDF only on Docsity! P a g e 1 | 22 1 Introduction & AIDET ***Knock Knock*** NR 304 – Health Assessment II Head to Toe Assessment Final Script Me: May I come in? Patient: Yes. Me: Hi, my name is (insert name) and I am a student nurse at Chamberlain University, and I have physician’s orders to perform a head to toe assessment on you which will take about 15-20 minutes, is now a good time? Patient: Yes. Me: I am going to start off with providing you with some privacy by closing off these curtains and taking care of my hand hygiene. ✓ close curtains ✓ perform hand hygiene ✓ put on gloves Me: Can I get your name and date of birth please? Patient: (Patient Name); June 27, 1999 Me: Okay, let me just check your wristband to verify. ✓ check wristband Guadalupe Jaime, June 27, 1999 Okay Ms. Jaime, are you allergic to any: food, medications shellfish iodine/betadine, latex, tapes or any other adhesives? Patient: No. Me: And are you in any pain today? Patient: No. Me: Okay, do you know where you are Ms. Jaime? P a g e 2 | 22 2 Patient: Chamberlain University Me: Okay, do you know what year it is? Patient 2019 Me: And do you know who our current president is? Patient: Donald Trump Me: Patient is alert and oriented (x4) Speech is clear and clothing is appropriate to time and place. General Appearance Me: Okay, we’re gonna go ahead and move on to your general appearance. ✓ look at the patient Posture is erect. Skin is appropriate to age. Skin color is appropriate to ethnicity. No signs of acute distress. Nutrition is adequate. Mood and behavior are appropriate to situation. And clothing is appropriate to situation as well. (No visible devices or equipment being used.) Vital Signs Me: I will now be taking your vital signs. ✓ check temperature o before checking the temp, ask if patient had anything hot or cold to drink, or smoked in the last 30 mins ✓ check the pulse oximetry ✓ take the blood pressure o ask if patient knows their usual blood pressure measurement ✓ check respirations o count for 30 seconds and multiple by 2 Skin & Nails Me: I’m gonna go ahead and start with your skin. Skin color is appropriate to ethnicity. There are no signs of lesions, incisions, wounds, rashes, and no tattoos visible. P a g e 5 | 22 5 clench your teeth o palpate side of cheeks while patient is clenching teeth Me: Okay, can you please close your eyes again for me ✓ begin to perform Q-tip sensory test on face Let me know if you feel anything and if and when you do, please say “now.” Patient: “Now. Now. Now. Now. Now.” Me: Okay, you can now open your eyes. Can you puff your cheeks? (patient will puff her cheeks) Now apply force against the resistance of my hand. (patient does this on both sides) Can you please raise your shoulders for me? (patient will shrug shoulders) Okay, cranial nerves V (5), VII (7), and XI (11) are all intact. Eyes Me: We will now move on with your eyes. Eyes are symmetrical with no signs of lesions, discharge, or infestations of the eyebrows, eyelashes, and eyelids. Okay, can you please look up at the ceiling for me? ✓ pull down the lower lid Sclera is white, conjunctiva is pink and moist. No signs of swelling or lesions noted. I’m gonna go ahead and check your pupils, and I’m gonna do that by shining a light on each of your eyes just for a brief moment, okay? ✓ use penlight to shine a light on each pupil, twice on each side Direct, consensual Now the other eye: direct, consensual If you could go ahead and stare at the tip of my pen, now over my left shoulder, tip of my pen, over my left shoulder again, tip of my pen Now just keep following my pen without moving your head, okay? ✓ perform the cardinal fields of gaze (up to 5 directions) Okay, patient’s PERRLA is well noted. Okay, now I’m gonna have you read the first line on the card for me please. P a g e 6 | 22 6 Patient: “Famous quotes by Albert Einstein.” Me: Okay, cranial nerve II (2) is intact. So now I’m gonna go behind you, and if and every time you see my finger, please say “now.” ✓ perform peripheral vision test (show finger 5 times on different sides) Patient: “Now. Now. Now. Now. Now.” Me: Okay, cranial nerves III (3), IV (4), and VI (6) are intact. Nose Me: Now we’re gonna go ahead and move on with your nose. Nose is symmetrical and midline to the body with no signs of lesions. Can you go ahead and tilt your head back for me? Okay, no foreign bodies, no deviated septum, and no drainage noted. Nose has two visible nares. ✓ begin to perform the sniff test Can you please close your eyes and go ahead and cover one nare for me please? Now breathe in, breathe out. While keeping your eyes closed, go ahead and cover your other nare for me, then breathe in, breathe out. Were you able to smell anything? Patient: Yes. Me: Okay, cranial nerve I (1) is intact. Did you have any trouble breathing? Patient: No. Me: Okay, bilateral patency is also well noted. Ears Me: We’re gonna go ahead and assess your ears. Ears are symmetrical and appropriately placed on the head and face. No lesions and no piercings visible. ✓ go on one side and check first ear with pen light P a g e 7 | 22 7 No skin breakdown in the front and the back of the ear. P a g e 10 | 22 10 Okay, can you go ahead and swallow for me please. ✓ patient swallows Can you go ahead and say “light, tight, dynamite” Patient: Light, tight, dynamite Me: Can you go ahead and stick your tongue out and move it side to side. ✓ patient will move tongue from side to side Okay, cranial nerves IX (9), X (10), and XII (12) are all intact. Neck Me: We’re gonna go ahead and move on to your neck. Neck is symmetrical, appropriately placed, and is midline to the body I’m now going to inspect your lymph nodes. Okay? ✓ palpate lymph nodes while verbalizing them preauricular posteriorauricular occipital jugulodigastric submandibular submental superficial cervical deep cervical posterior cervical supraclavicular Did you feel any tenderness? Patient: No. Me: Okay, lymph nodes are non-tender and non-palpable. No masses noted. Respiratory Anterior Me: I’m gonna go ahead and inspect your chest. First, AP diameter is less than transverse. To the back, no signs of scoliosis, lordosis, or kyphosis. I’m gonna go ahead and palpate your chest okay? And let me know if you feel any tenderness. Okay? P a g e 11 | 22 11 ✓ palpate the chest Did you feel any tenderness? Patient: No. Me: Okay, no masses, no tenderness. I’m gonna go ahead and also palpate your back. Did you feel any tenderness? Patient: No. Me: Okay, no tenderness, no masses, and temperature is normal. Okay, before I listen to your lung sounds, I’m gonna go ahead and clean my stethoscope. Now, I’m gonna go ahead and warm it up. ✓ clean both diaphragm and bell of the stethoscope, warm it up in your hands Okay, so now we are ready to listen to your lung sounds. When I touch you with my stethoscope, you’re gonna go ahead and breathe in and out for me, okay? Patient: Okay. Me: Respiratory Anterior: ✓ auscultate 8 positions and verbalize position; order is below: RUL LUL RUL LUL RML LUL RLL LLL ✓ Note: RML is in line with the nipple. Me: Lung sounds are clear anteriorly. No accessory muscles used. Respiratory Posterior: Me: Okay, I’m gonna go ahead and do the same for your back. Now, same thing in the back as in the front, when I touch you with my stethoscope, go ahead and breathe in and out for me, okay? Patient: Okay. P a g e 12 | 22 12 ✓ auscultate 8 positions and verbalize position; order is below: P a g e 15 | 22 15 Me: No bruits are noted to these areas. P a g e 16 | 22 16 I am going to go ahead and palpate really lightly okay. Patient: Okay ✓ palpate all four quadrants and verbalize Me: Did you feel any pain with that? Patient: No pain. Me: Okay we are now finished with the abdomen. Musculoskeletal: Me: I am going to go ahead and complete your musculoskeletal exam. If you can just go ahead and grab my both hands for me and pull as hard as you can. ✓ patient PULLS against resistance of the arm Me: Now go ahead and push. ✓ patient PUSHES against resistance of the arm Me: Now go ahead and put your arms like this and pull and then push ✓ grab patient midway bet forearm and wrist and patient PULLS and PUSHES Me: Patients strength was 5 out of 5. Now I am going to go ahead and assess your reflexes at this point okay? I am going to go ahead and start at the: bicep - do reflex brachioradialis - do reflex triceps - do reflex ✓ move to the other arm and repeat all 3 bicep - do reflex brachioradialis - do reflex triceps - do reflex ✓ do reflex and set hammer down Me: I am going to test your muscular strength at the bottom as well. Can you push against my hands? P a g e 17 | 22 17 ✓ patient pushes on hands with feet P a g e 20 | 22 20 ✓ perform capillary refill by pinching each finger on both feet Me: Capillary refill is less than 2 seconds bilaterally. REMOVE GLOVES AND SIMULATE HAND HYGIENE., THEN PUT ON NEW GLOVES Me: Go ahead & move your elbows up and down for me. - patient does it Me: Move your wrist into circles. Bring your fingers out like this for me Move one leg up and down Now the other leg up and down. Rotate your ankles for me - patient does it - patient does it - patient does it - patient does it - patient does it Me: Go ahead and stand up Face me and rotate your head Move one arm into a big circle Now the other arm Abduction out Adduction in - patient does it - patient does it - patient does it - patient does it - patient does it - patient does it Me: Place one arm on the bed and bring the leg into abduction Turn for me and do the same thing with the other leg Now go ahead and walk towards the front for me Turn around and walk on back for me Now go ahead & stand real still for me & close your eyes - patient does it - patient does it - patient does it - patient does it - patient does it - place hands on side of patient for a couple of seconds Me: Okay now I am going to go ahead and have a seat for me. Patient’s Romberg test is negative Your gait is even and smooth ` Muscle strength is a 5/5 Reflexes are 2+ Full range of motion (ROM) is intact. Closure: Me: Okay Ms. Jaime, that concludes your head to chest assessment. Are you in any pain? Patient: No Do you feel comfortable? Patient: Yes Do you need anything else right now? Patient: No Is there anything else I can do for you? Patient: No Okay, I’m gonna go ahead and document my findings, and the physician will be here shortly. I am going to lower your bed into the lowest position and make sure it is locked, and hand you your call light in reach. If there is anything else, I can do for you, just let me know. Thank you for your time. P a g e 21 | 22 21 ✓ take out gloves, perform hand hygiene, provide privacy P a g e 22 | 22 22