“Hello my name is Jennifer, I’m going to be your nurse today. How are you doing?”
“Can you tell me your name and date of birth” Look at wristband.
Close curtain. Wipe down bedrails and table.
“I know this sounds silly but do you know where you are today? And what brought you in today?”
“Patient is alert and oriented”
“Today I am going to do a head-to-toe assessment if that’s okay with you. It’s just a test of your different body systems to get some important data.”
“I’m going to start by assessing your cranial nerves to make sure they’re all functioning properly, first will be cranial nerve 1, which is scent”
Use alcohol swab for each nostril, ask if smell is equal on both sides.
“Now I’m going to check your eyes”
Use Snellen chart. Tell patient to focus on something in the distance and then follow penlight toward the nose. Check pupil accommodation to light. 6 cardinal fields. Peripheral vision by wiggling fingers from behind patient toward face. Then cover one eye and do again, then other eye.
“Now I’m going to check your hearing”
Use whisper test
“Now I’m going to check your facial nerves”
Palpate jaw bone while patient open and closes mouth. Have them close eyes and touch face with cotton.
“Now I just want to check for facial symmetry, can you smile for me? Now raise your eyebrows. Now puff out your cheeks and I’m going to press them”
“Can you shrug your shoulders for me? Now can you turn your head against my hand?
“Now I just need you to swallow, great now can you stick out your tongue and say ah? Perfect, your uvula raises and stays midline and your tongue stays midline. Now just repeat after me, light, tight, dynamite.”
“Now we’re on to the head part of the assessment. I am just inspecting your head for symmetry, general size, and shape. Head is normocephalic!”
“Your facial expression is appropriate, there is no abnormal swelling.”
Palpate skull for symmetry and smoothness, lesions, lumps, bruising.
“It looks like your ears have bilateral symmetry, they aren’t swollen or thickening, the color is normal and the skin is intact”
Ask if patient feels any tenderness while moving cartilage and pushing tragus.
Inspect eyes for bilateral symmetry. Check for smooth eyebrows and thick eyelashes. Pull top and bottom eyelids to check for crusting and discharge.
“Your nose is symmetric and midline. Your septum is proportionate. Palpate, ask for pain. Frontal (right above eyebrows) Maxillary (next to nose) Make sure orbital bone is intact.
7) Mouth and Throat
Have patient open mouth. Inspect mucous membranes for color, lesions, plaques, moisture. Check teeth and gums for dental carries. No cracking of lips.
Check that trachea is midline
Palpate all lymph nodes, Small circular motions. “If enlarged more than 1cm, it would indicate localized infection or allergy and follows the direction of lymphatic drainage.
Preauricular-in front of ears
Occipital-base of skull
Submandibular-middle of jaw
Jugulodigastric-beginning of jaw
Supraclavicular-ask patient to shrug shoulders
Thyroid-apply pressure to one side and palpate other side. Ask patient to swallow.
Assess extension, flexion, right and left lateral bending and right and left rotation of head.
Palpate carotid artery ONE SIDE AT A TIME.
Auscultate carotid artery using BELL.
“I don’t hear any bruits. That’s what I like to see.”
10) Skin, hair, nails
Assess skin for dryness,…