Knock.
Hello, my name is Ashley. I’m going to be your student nurse today, is it okay if I come
in?
Enter. Hand hygiene. Gloves.
I’m going to be doing a head-to-toe assessment. It should only take 30 minutes and I will
need to touch you. Is that okay?
Great, can you tell me your name and DOB?
Do you have any allergies?
Are you in any pain? On a scale of 0-10, 0 being no pain at all 10 being the worst?
Can you tell me where you are and what year it is?
Patient is alert and oriented x4. No signs of discomfort, well-groomed and dressed
appropriately.
I’m going to say 4 words, remember them, I will have you repeat them to me later. Dog,
Cat, Dog, Cat
Can you go ahead and give me a urine sample. Here’s the cup you can walk that way and
then bring it back.
Hand urine cup.
Patient walks with normal gait. They are steady and coordinated.
Assess urine sample.
Have you had any pain or urgency with urination? Urine is yellow, odorless, and clear of
sediment.
CHANGE GLOVES
Can you repeat the 4 words to me? Short and Long term memory intact.
While you are standing we are going to asses your musculoskeletal system.
Have patient bend forward. Inspect and palpate spine.
Spine is straight. No spasms or tenderness.
Bend forward/back, side/side, twist at waist. Arms up, back, behind head, circles. Swing legs
front and back, bend arm, bend wrist/twist. Soles in/out
Have patient sit. Assess strength in hands, gas pedal/toes up.
No limitation or crepitus in joints, symmetrical movement, muscles have equal strength.
I’m going to go ahead and assess your cranial nerves.
Hello, my name is Ashley. I’m going to be your student nurse today, is it okay if I come
in?
Enter. Hand hygiene. Gloves.
I’m going to be doing a head-to-toe assessment. It should only take 30 minutes and I will
need to touch you. Is that okay?
Great, can you tell me your name and DOB?
Do you have any allergies?
Are you in any pain? On a scale of 0-10, 0 being no pain at all 10 being the worst?
Can you tell me where you are and what year it is?
Patient is alert and oriented x4. No signs of discomfort, well-groomed and dressed
appropriately.
I’m going to say 4 words, remember them, I will have you repeat them to me later. Dog,
Cat, Dog, Cat
Can you go ahead and give me a urine sample. Here’s the cup you can walk that way and
then bring it back.
Hand urine cup.
Patient walks with normal gait. They are steady and coordinated.
Assess urine sample.
Have you had any pain or urgency with urination? Urine is yellow, odorless, and clear of
sediment.
CHANGE GLOVES
Can you repeat the 4 words to me? Short and Long term memory intact.
While you are standing we are going to asses your musculoskeletal system.
Have patient bend forward. Inspect and palpate spine.
Spine is straight. No spasms or tenderness.
Bend forward/back, side/side, twist at waist. Arms up, back, behind head, circles. Swing legs
front and back, bend arm, bend wrist/twist. Soles in/out
Have patient sit. Assess strength in hands, gas pedal/toes up.
No limitation or crepitus in joints, symmetrical movement, muscles have equal strength.
I’m going to go ahead and assess your cranial nerves.
