Jordan Flashcards
1
My name is Melissa and I’ll be doing your head to toe assessment today. I’m going to wash my hands and then we’ll get started.
Pull privacy curtain
2
Can you tell me your first and last name and date of birth?
May I see your wristband?
3
Are you in a comfortable position to get started?
Are you in any pain today?
4
I’m going to check your temperature. Can you hold this under your tongue?
Read temperature.
5
Next I’d like to take your pulse.
Pulse is a plus 2 and___________ (74)
6
I’d like to observe your breathing.
Could you breathe normally for me?
Report respirations
7
Great. I’m going to check your oxygen levels now. I’m going to place this probe on your index finger. Can you please hold still while it’s working?
Report O2 levels
8
Next I’d like to take your blood pressure.
I’m going to feel for your brachial pulse up here on your arm. Great, it’s a plus two, lets get started.
Report blood pressure
9
Can you tell me where you are?
What time of day is it?
Patient is conscious, and oriented to person, place, and time. She has appropriate speech and good posture and hygiene.
9
Alright. Can I have you smile for me? Puff out your cheeks? Raise your eyebrows? Great.
10
I’d like to examine your eyes. Can you look straight ahead at my nose?
Pupils are equal, round, reactive to light, and accommodation. There is no redness or discharge.
11
Next I’d like to take a look in your nose, mouth, and ears. Can you place your finger over each nostril and blow air through your nose on both sides?
I’d like to check your hearing. I’m going to stand behind you and whisper three words into each ear and I’d like you to repeat them back to me.
Purple seven pizza
Okay, hearing is good, Nose is free of discharge and mucous membranes look normal and moist. Ears are free of wax.
12
I’d like to listen to your lungs now. Auscultate breath sounds.
Check spinal alignment.
Normal respiratory rate, rhythm, and depth. Normal breath sounds with no wheezing or crackles. No use of accessory muscle or cough. Spinal alignment is normal.
13
Now I’m going to feel the artery in your neck and listen to your heart.
Carotid artery is a plus 2 on both sides and patient has strong S1 and S2 sound with no murmur.
14
I’m going to inspect your stomach now. Could you lie back for me?
Listen to all 4 quadrants
Patient’s abdomen is non-tender and symmetrical in shape. Normal bowel sounds.
I’m going to gently press on your belly now. Can you let me know if any areas or tender or uncomfortable? A
Are you experiencing any issues with urinating or bowel movements? When was your last bowel movement?
15
I’m going to check your arms and legs for swelling now. Could you tell me if you feel any pain?
Arms and legs are symmetrical. Skin is warm, dry, and intact there is no edema present.
16
Check capillary refill.
State that it is normal.
17
Check pulses.
Posterial tibial
Dorsal pedis
State that posterial tibial is 2+ and dorsal pedis has a strength of 1+ and all are symmetrical.
18
I’m going to check your strength and range of motion now. Can you look up? Down? To the left? And to the right? Good. Now I’d like to start with pushing against your legs. Can you try to resist?
Now I’m going to try to pull them towards me, can you try to resist?
19
Let’s move on to the arms. I’m going to place my hands on your shoulders. Can you shrug? Okay, now can you hold your arms up and out in front of you? I’m going to push against them. Can you resist?
State that patient has full range of motion in upper and lower extremities. They are equal and strong bilaterally without pain.
20
Can I have you stand up and stand on one foot? How about the other?
Can you walk over to wall and back.
Patient has steady balance and gait.
21
Are you comfortable?
Thank you, our head to toe assessment is finished. The doctor will be in soon.
