NR 304 Health Assessment II Head to Toe Assessment Final Script (Latest, 2022/2023), Study Guides, Projects, Research of Nursing

Download NR 304 Health Assessment II Head to Toe Assessment Final Script (Latest, 2022/2023) and more Study Guides, Projects, Research Nursing in PDF only on Docsity! NR 304 — Health Assessment II Head to Toe Assessment Final Script Introduction & AIDET *** Knock Knock*** 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: Tam going to start off with providing you with some privacy by closing off these curtains and taking care of my hand hygiene. V close curtains Vv __ perform hand hygiene J 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. VY 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? Patient: Chamberlain University Me: Okay, do you know what year itis? 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. V_ 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. Vv check temperature 0 before checking the temp, ask if patient had anything hot or cold to drink, or smoked in the last 30 mins Vv. check the pulse oximetry V take the blood pressure 0 ask if patient knows their usual blood pressure measurement V_ check respirations © 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. I’m gonna go ahead and check for your temperature. Patient: Me: Patient: Patient: Me: Patient: “Famous quotes by Albert Einstein.” 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. V_ perform peripheral vision test (show finger 5 times on different sides) “Now. Now. Now. Now. Now.” Okay, cranial nerves III (3), IV (4), and VI (6) are intact. 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. V_ 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? Yes. Okay, cranial nerve I (1) is intact. Did you have any trouble breathing? No. Okay, bilateral patency is also well noted. 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. VY goonone side and check first ear with pen light No skin breakdown in the front and the back of the ear. Patient: Me: Patient: Me: Patient: Me: Mouth and Throat Me: No foreign bodies, no swelling, no redness, and no dischargel will now be palpating your tragus, okay? Vv palpate tragus Any tenderness? No Okay, I will go ahead and do the same for the other side. No skin breakdown in the front and back of the ear. No foreign bodies, no swelling, no redness, and no dischargel will now palpate your tragus. Vv palpate tragus Any tenderness? No. Okay, and Ms. Jaime, do you have any hearing loss? No. Okay, no usage of hearing devices noted. I will go ahead and perform a hearing test, and all you have to do is repeat the word that Iwill whisper behind you, while you cover one of your ears for me okay? V_ perform hearing test for both ears/sides, only use multiple syllable words Okay, cranial nerve VIII (8) is intact. I’m gonna go ahead and look at your mouth. Lips are properly aligned, symmetrical on the face, and midline to the body Lips are pink and moist with no signs of cracking and no lesions Can you go ahead and open your mouth for me? Vv check patient’s mouth with penlight and tongue blade Teeth are intact, no signs of cavities, oral muscosa, gums and tongue are pink and moist,no odor noted. Can you go ahead and say “aaaaahhhh’”? Vv patient will open mouth, say “ahhhhh”, while sticking tongue out Vv check patient’s mouth with penlight and tongue blade Okay, uvula is midline, rise and fall is normal Okay, can you go ahead and swallow for me please. Vv 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. Vv 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? V_ palpate lymph nodes while verbalizing them preauricular posteriorauricular occipital jugulodigastric submandibular submental superficial cervicaldeep 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? Gastrointestinal: Me: Me: Patient: Vv check on both sides for the carotid pulse Carotid pulse is 2+ and normal. V take pillow out of bed I’m now gonna have you lay back for me. V take out the tray for the legs Turn your head to the left. No JVD noted. Okay, can you go ahead and sit up for me. V_ lower the bed even more (flat position) Tam going to go ahead and assess your abdomen at this point, so I will go ahead and ask you to lay back down. V_ inspect abdomen looking from the side Skin color is appropriate to race and ethnicity. There are no surgical incisions, scars, rashes, lesions, or excoriations noted to the skin. Contour is flat, and all four quadrants are symmetrical. There are no masses or pulsations noted to the abdomen. V_ move to the front of abdomen and inspect Moving down here again I see symmetry in all four quadrants, a flat contour, and there are no masses or pulsations noted. V move to the side to begin auscultating Is it okay if I begin to auscultate your bowel sounds? Yes. VY auscultate all four quadrants with diaphragm first and verbalize Bowel sounds are normal active in all four quadrants. Now I'll be switching to my bell and listening to any potential bruits. Vv switch to the bell and auscultate, and verbalize: epigastric, umbilical, and super pubic No bruits are noted to these areas. Patient: Me: Patient: Me: Musculoskeletal: Me: Tam going to go ahead and palpate really lightly okay. Okay V_ palpate all four quadrants and verbalize Did you feel any pain with that? No pain. Okay we are now finished with the abdomen. Tam going to go ahead and complete your musculoskeletal exam. Tf you can just go ahead and grab my both hands for me and pull as hard as you can. V_ patient PULLS against resistance of the arm Now go ahead and push. V_ patient PUSHES against resistance of thearm Now go ahead and put your arms like this and pull and then push V grab patient midway bet forearm and wrist and patient PULLS and PUSHES Patients strength was 5 out of 5. Now I am going to go ahead and assess your reflexes at this point okay? am going to go ahead and start at the: bicep - do reflex brachioradialis - do reflex triceps - do reflex VY move to the other arm and repeat all 3 bicep - do reflex brachioradialis - do reflex triceps - do reflex Vv doreflex and set hammer down Tam going to test your muscular strength at the bottom as well. Can you push against my hands? V_ patient pushes on hands with feet Peripheral Vascular Me: Me: Patient: Me: Now pull against my hands V_ patient pulls on hangs with feet Now | am going to use the flat edge to ass s your reflexes okay V_ grab hammer Patellar Vv doreflex on both legs, hold foot Achilles’ Vv doreflex on both legs Ok now I am going to assess your peripheral vascular system on the legs can you go ahead and raise up your pant legs for me. V_ patient will raise up her pants Do you shave? Yes. Okay hair distribution is even. Skin color is appropriate to race and ethnicity. There are no wounds, rashes, lesions, or tattoos noted. There are no ulcers noted to the feet. Tam going to go ahead and palpate your legs. V_ palpate legs Skin is warm to touch. Tam going to go ahead and assess for edema. V_ poke legs from up to bottom on both legs There is no pitting edema noted bilaterally. Tam going to go ahead and assess the dorsalis pedis pulse. V_ check dorsalis pedis pulse on both legs at the same time It is 2+ and equal bilaterally. I’m gonna go ahead and check for capillary refill.