Head-to-toe assessment script

Hello my name is Sheila and I will be you Barry University Student Nursetoday.I will be performing a head to toe assessment today and I will be touchingand examining you.Is this OK?I will begin by washing my hands for 40- 60 seconds to prevent infections.I will look at the patient’s bracelet and ask him his full name and date ofbirthI will continue to test my patient’s Glasgow Coma Scale. I will ask himDo you know where you are?Do you know what date is today?Do you know why you are here?Can you shake my hand?The patient is Alert, Awake and Oriented X4. Which means he is alert andoriented to person, place, time, situation. The patient also had a GlasgowComa Scale of 15 which means his eyes were open spontaneously when Iwalked into the room. He is Alerted, Awake and oriented x 4 and lastly, heobeys motor commands because he was able to firmly shake my hand.During today’s assessment I will be using my stethoscope, penlight andwatch with a second hand and I will be closing curtains or door to provideprivacy for the patient.I will first take the patient’s vital signs including, temperature, heart rate,respiratory rate, oxygen level and any type of pain.My overall impression of the client is that he appears to be of hischronological age and has appropriate sexual development.His skin color is even and has no variations, no pallor, cyanosis, jaundice,or flushed skin.Patient seems clean, with no odor, well-groomed and dressed appropriatefor the occasion and weather.Patient is able to sit erect and stand without support.When I ask client to walk to scale, I observed his gait, which is even andcoordinated.I obtained height and weight to assess BMI (Body Mass Index) in order toassess his nutritional status.His BMI is within the normal rage of 19-24.Below 19 (Underweight) causes may be anorexia, malnutrition, alcoholismAbove 30 to 39 (Obese) causes heart disease, diabetes type 2 The patient shows no signs of distress, anxiety or discomfort. The patient isalso cooperative, happy and answers questions appropriately with clear.......r ( college/uni name)IttNAGGERS speech, no slurring and equal facial expression. The patient is also able tomaintain eye contact and follow instructions well.I will continue the assessment by inspecting and palpating the face andhead.Inspecting the head which is normocephalic, no lesions, lumps,parasites. Hair distribution even, smooth. May be dry or oily. No baldingareas or alopecia.I will put on my gloves to continue with the palpation of the head.The head is hard and smooth, it has no lumps, equal hair distribution, noalopecia which is loss of hair, and color chemically or natural should beeven.As I inspect the face it should be symmetric with a round appearance andno abnormal movements with appropriate expression such as tremor, theskin should be clear with no rash or reddened areas. The top of earsshould level the corner of the eyes.I will begin to test Cranial nerve 1 which is Olfactory.Inspecting the nose, it should be straight, with no drainage, and noswelling. I will test this nerve by asking the patient to seat in a comfortableposition at my eye level. I will ask him to occlude one nostril and ask him totake a deep breath with his mouth close and to repeat the same with theopposite nostril. After making sure none of the nostril are congested, then Iwill ask my patient to close their eyes and while one of their nostrils is coverthen I will have them identify a familiar scent such as alcohol, or coffee.Repeat it with the opposite nostril. Client should be able to identify thesmell.I will continue to test Cranial Nerve 7 which is Facial.I will be testing the facial motor function of the patient. I will ask the patientto smile, frown, puff his cheeks, raise eyebrows and show teeth. Themovements should be symmetrical. In addition to this, I will test thepatient’s taste by placing a cotton swab with sour, sweet or bitter taste andask the patient to identify the different tastes. Moving down to the mandible I will continue to palpate and test thetempomandibular joint. There should be no swelling, tenderness, no painor crepitation with movement. I will ask my patient to open and close mouthfully. Then, I will ask him to move jaw laterally, protrude which means tomove out and to retract which means to pull back. I will continue to test Cranial Nerve 5 which is TrigeminalThis nerve is responsible for motor function and sensory. To test the motorfunction, I will ask my patient to clench his teeth, and I should feel thetemporal and masseter muscles. To test the sensory, I will ask my client toclose his eyes and identify between dull and sharp.I will say:“This is dull (touch him with dull) and this is sharp (touch him with sharp)” Then I will touch regions in the cheeks, forehead, and chin bilaterally.I will continue inspecting the eyes.The eyes should be symmetrical. Eyelashes are evenly distributed andcurve outward along the lid margins. Skin on both eyelids is withoutredness, swelling, or lesions. There is no drainage.Bulbar conjunctiva is pink, clear, moist, and smooth. Underlying structuresare clearly visible. Sclera is white. Test peripheral vision.To test the peripheral vision, I will perform confrontation testI will position myself approximately 2 ft. away from theclient at eye level. I will have my patient cover the left eye while I cover myright eye. We will look directly at each other with our uncovered eyes. Next,fully extend your left arm at midline and slowly move one finger upwarduntil the client is able to see the finger. To continue testing the eyes I will test Cranial Nerve 2 which is OpticFor this nerve we will be testing for visual acuity and pupillary responses.To test distant visual acuity, I will need a Snellen Chart where normal acuity is20/20 with or without corrective lenses.The top or first number is always 20 which indicates the distance of the patientfrom the chart. The bottom or second number refers to the last full line the clientcould read. This means that the client can distinguish what a person will normalvision can distinguish from 20 feet away. I will continue to perform the PERLA test for the pupil reaction. PERLA stand for