CPE SCRIPT 3160 HEAD-TO-TOE ASSESSMENT
Knock knock
Provides privacy
Hand hygiene
Hello my name is Shyler and I will be your student nurse today. I’m going to be doing a head-to-toe assessment it will take about 30 minutes and
it does involve touch. Are you okay with that?
Can you tell me your name, date of birth, and any known allergies (while checking wristband)
• AIDET
◦Do you know where you are ?
◦What is today’s date and time ?
◦Who is the president ?
‣ patient appears alert & oriented (A&O) X4
‣ patient appears calm, well-groomed, and appropriately dressed
• BEFORE BEGINNING ASSESSMENT
◦Can I ask you to empty your bladder so I can collect a urine sample
‣ watch patients gait as they walk to the restroom
• gait is steady, even, balanced, symmetrical, and coordinated
◦ Did you have any pain, burning, or straining while urinating?
‣ COACH: the urine is yellow without sediment, odorless, and about 50mL
‣ *HAND HYGIENE/CHANGE GLOVES (after touching urine specimen)*
◦When was your last bowel movement?
‣ was it normal?
◦How often do you perform self-breast exams?
◦When was the first day of your last menstrual cycle?
‣ How long does your cycle last, does your cycle come at the same time of the month, is your cycle irregular
• NEURO/HEENNT/LYMPH NODES/CARDIAC/RESPIRATORY ASSESSMENT
◦Now I’m going to look at your scalp
‣ Hair is evenly distributed, no alopecia, no lumps, bumps, tenderness, or skin issues noted
◦Now I’m going to check the sensation on your face, can you please close your eyes
‣ Touch with dull and sharp object and ask patient where they where touched
• forehead
• Nose
• Left cheek/Right cheek
• Chin
‣ CN 5 is intact and sensation is intact at all locations touched
◦While keeping your eyes closed can you identify this smell
‣ Alcohol swab test
‣ CN 1 is intact
◦You can open your eyes
◦Now I’m going to check your eyes
‣ I will be shining a light to check for PERRLA
• Pupils are Equal, Round, Reactive to Light and Accommodation
‣ Pull bottom eyelids down and check conjunctiva and sclera
• CONJUNCTIVA: clear, pink, moist
• SCLERA: white, no cloudiness
‣ Can you follow my light with your eyes only (please do not move your head)
• 6 cardinal signs of gaze
‣ Now can you look at the Snellen chart and read the lowest letters you can see
, ‣ CN: 2,3,4,6 are intact
◦Next I’m going to assess your nose
‣ Shine light in patients nose
‣ Note no deviated septum and nostrils are symmetrical
‣ Mucosa is pink and moist with no lesions, lumps, bumps, or pain
◦Now I’m going to check your ears and your hearing
‣ Shine light into ear
• no redness, drainage, or swelling
‣ Ears are appropriate for body size
‣ Ears are symmetrical
‣ Now I’m going to palpate your ears
‣ No swelling, redness, lesions, lumps, bumps or tenderness
‣ Now if you can sit up straight I’m going to conduct the whisper test
‣ Cover one ear and repeat after me 123, Cover the other ear and repeat A,B,C
‣ CN: 8 is intact
◦Now we are going to look for symmetry in your face
‣ Can you smile, frown and puff your cheeks for me
‣ Can you clench your teeth while I palpate your jaw muscles
‣ Can you open your mouth and say “AHHHHHH” (inspect with light while pt does this)
• Teeth - intact, normal color, gums are pink
• Tongue - no lesions, no discoloration
• Throat no redness, discoloration, exudate from tonsils
• Lips - are moist, pink, no cracking, and lesions
‣ *HAND HYGIENE/CHANGE GLOVES (after assessing mouth)*
‣ Can you move your tongue side to side
‣ Ask pt if they can swallow
• gag reflex intact
‣ CN: 9,10,12 are intact
◦Can you rotate your head to each side
‣ Stand on right side of bed
‣ NO JVD NOTED
• (HEAD OF BED AT 30-45)
◦Now can you shrug your shoulders while I apply pressure
‣ CN: 11 & 12 are intact and strong muscle movement bilaterally
◦Next we are going to palpate your lymph nodes
Knock knock
Provides privacy
Hand hygiene
Hello my name is Shyler and I will be your student nurse today. I’m going to be doing a head-to-toe assessment it will take about 30 minutes and
it does involve touch. Are you okay with that?
Can you tell me your name, date of birth, and any known allergies (while checking wristband)
• AIDET
◦Do you know where you are ?
◦What is today’s date and time ?
◦Who is the president ?
‣ patient appears alert & oriented (A&O) X4
‣ patient appears calm, well-groomed, and appropriately dressed
• BEFORE BEGINNING ASSESSMENT
◦Can I ask you to empty your bladder so I can collect a urine sample
‣ watch patients gait as they walk to the restroom
• gait is steady, even, balanced, symmetrical, and coordinated
◦ Did you have any pain, burning, or straining while urinating?
‣ COACH: the urine is yellow without sediment, odorless, and about 50mL
‣ *HAND HYGIENE/CHANGE GLOVES (after touching urine specimen)*
◦When was your last bowel movement?
‣ was it normal?
◦How often do you perform self-breast exams?
◦When was the first day of your last menstrual cycle?
‣ How long does your cycle last, does your cycle come at the same time of the month, is your cycle irregular
• NEURO/HEENNT/LYMPH NODES/CARDIAC/RESPIRATORY ASSESSMENT
◦Now I’m going to look at your scalp
‣ Hair is evenly distributed, no alopecia, no lumps, bumps, tenderness, or skin issues noted
◦Now I’m going to check the sensation on your face, can you please close your eyes
‣ Touch with dull and sharp object and ask patient where they where touched
• forehead
• Nose
• Left cheek/Right cheek
• Chin
‣ CN 5 is intact and sensation is intact at all locations touched
◦While keeping your eyes closed can you identify this smell
‣ Alcohol swab test
‣ CN 1 is intact
◦You can open your eyes
◦Now I’m going to check your eyes
‣ I will be shining a light to check for PERRLA
• Pupils are Equal, Round, Reactive to Light and Accommodation
‣ Pull bottom eyelids down and check conjunctiva and sclera
• CONJUNCTIVA: clear, pink, moist
• SCLERA: white, no cloudiness
‣ Can you follow my light with your eyes only (please do not move your head)
• 6 cardinal signs of gaze
‣ Now can you look at the Snellen chart and read the lowest letters you can see
, ‣ CN: 2,3,4,6 are intact
◦Next I’m going to assess your nose
‣ Shine light in patients nose
‣ Note no deviated septum and nostrils are symmetrical
‣ Mucosa is pink and moist with no lesions, lumps, bumps, or pain
◦Now I’m going to check your ears and your hearing
‣ Shine light into ear
• no redness, drainage, or swelling
‣ Ears are appropriate for body size
‣ Ears are symmetrical
‣ Now I’m going to palpate your ears
‣ No swelling, redness, lesions, lumps, bumps or tenderness
‣ Now if you can sit up straight I’m going to conduct the whisper test
‣ Cover one ear and repeat after me 123, Cover the other ear and repeat A,B,C
‣ CN: 8 is intact
◦Now we are going to look for symmetry in your face
‣ Can you smile, frown and puff your cheeks for me
‣ Can you clench your teeth while I palpate your jaw muscles
‣ Can you open your mouth and say “AHHHHHH” (inspect with light while pt does this)
• Teeth - intact, normal color, gums are pink
• Tongue - no lesions, no discoloration
• Throat no redness, discoloration, exudate from tonsils
• Lips - are moist, pink, no cracking, and lesions
‣ *HAND HYGIENE/CHANGE GLOVES (after assessing mouth)*
‣ Can you move your tongue side to side
‣ Ask pt if they can swallow
• gag reflex intact
‣ CN: 9,10,12 are intact
◦Can you rotate your head to each side
‣ Stand on right side of bed
‣ NO JVD NOTED
• (HEAD OF BED AT 30-45)
◦Now can you shrug your shoulders while I apply pressure
‣ CN: 11 & 12 are intact and strong muscle movement bilaterally
◦Next we are going to palpate your lymph nodes
