Jordan

Question 1

1

Answer 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

Question 2

2

Answer 2

Can you tell me your first and last name and date of birth?

May I see your wristband?

Question 3

3

Answer 3

Are you in a comfortable position to get started?

Are you in any pain today?

Question 4

4

Answer 4

I’m going to check your temperature. Can you hold this under your tongue?

Read temperature.

Question 5

5

Answer 5

Next I’d like to take your pulse.

Pulse is a plus 2 and___________ (74)

Question 6

6

Answer 6

I’d like to observe your breathing.
Could you breathe normally for me?

Report respirations

Question 7

7

Answer 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

Question 8

8

Answer 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

Question 9

9

Answer 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.

Question 10

9

Answer 10

Alright. Can I have you smile for me? Puff out your cheeks? Raise your eyebrows? Great.

Question 11

10

Answer 11

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.

Question 12

11

Answer 12

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.

Question 13

12

Answer 13

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.

Question 14

13

Answer 14

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.

Question 15

14

Answer 15

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?

Question 16

15

Answer 16

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.

Question 17

16

Answer 17

Check capillary refill.

State that it is normal.

Question 18

17

Answer 18

Check pulses.

Posterial tibial
Dorsal pedis

State that posterial tibial is 2+ and dorsal pedis has a strength of 1+ and all are symmetrical.

Question 19

18

Answer 19

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?

Question 20

19

Answer 20

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.

Question 21

20

Answer 21

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.

Question 22

21

Answer 22

Are you comfortable?

Thank you, our head to toe assessment is finished. The doctor will be in soon.