Introduction
(Knock on door)
1. Hi, my name is Casarra and I will be your nurse for today.
I am going to close the door for patient privacy. Wash my hands for 20 seconds per CDC
guidelines and don clean gloves. May I please have your full name and DOB? Do you have an
allergies? (Check in patient’s chart and ask patient to verify what they are allergic too)
I will be doing your head-to-toe physical assessment. I will need to inspect, tough, and listen to
different parts of your body. This will help me gather a baseline of your overall health and bod
systems. Is that okay with you? Great! I will be asking you some questions, ask for simple
commands, and explain what I will be doing. It will roughly take 15-17 minutes. Do you have
any questions?
(Provide privacy, adjust the bed, environmental safety check)
Iwillraiseupthebed,lowerthesiderailsandHOBat45.
2. I know I already asked you for your name and DOB but can you please state it again?
(check wrist band)
3. General Survey: a. Do you know what year it is? 2025
b. Do you know where you are? WCU hospital
c. Do you know why you are here? For your annual check up
d. Do you know who the current president is? Trump
Pt is A&O x4 to person, time, place, and situation. Recent and remote memory intact.
Pt is calm & cooperative, able to speak clearly, appears her stated age, well-groomed, and dressed
appropriately. Responds to questions appropriately. No hearing aids. Able to track and maintain eye
contact. No acute distress noted.
4. Do you have any pain right now? No
If pt was in pain, I will use the PQRST scale. “What makes it worse or better? What does
pain feel like? Where is the pain exactly? Does it spread anywhere? How bad is the pain fro
1-10? When does it occur and how long does it last?”
Head to JVD (hair, skin, eyes, nose, mouth)
1. First, I will inspect your hair and skin.
(separate hair 1” apart at a time, run fingers through scalp)
Hair is evenly distributed, no infestations, no dandruff, no bumps.
(feel temperature of the skin..forehead neck, and press into mandible)
Skin is warm, dry, intact, no scars, lesions, or edema. Skin is appropriate to ethnicity.
2. Now I will inspect your ears.
(check if symmetrical, use penlight, 1” from each ear, pull pinna back inspect ear with penlight, palpate
for any tenderness and ask if patient feels pain or tenderness)
Ears are symmetrical, no signs of redness or drainage in both ears, no lesions or tenderness or
pain when palpated.
3. Next I will inspect your face.
(check for symmetry – facial droop, color (pale, flushed, jaundice)
I can see it’s symmetrical. Skin color is appropriate for ethnicity. No lacerations. Skin integrity
intact. Can you smile and raise eyebrows for me? No facial drooping noted. Can you close your
eyes and tell me which side I’m touching?
Keep your eyes closed and tell me what you smell. Ok its alcohol. Facial sensation and ability
smell intact.
4. Next, I will inspect your eyes.
(ask to remove glasses if any, inspect sclera, and pull down under eyes to see conjunctiva sac)
Eyes are symmetrical, sclera are pearly white. Do you wear glasses or contacts? Okay, Any
issues with vision lately? I’m going to pull down under eyelids. The conjunctiva sac is pink and
moist. No redness and abnormal findings noted.
I am going to dim the lights, please stare straight ahead while I shine a light into your eyes.
(Knock on door)
1. Hi, my name is Casarra and I will be your nurse for today.
I am going to close the door for patient privacy. Wash my hands for 20 seconds per CDC
guidelines and don clean gloves. May I please have your full name and DOB? Do you have an
allergies? (Check in patient’s chart and ask patient to verify what they are allergic too)
I will be doing your head-to-toe physical assessment. I will need to inspect, tough, and listen to
different parts of your body. This will help me gather a baseline of your overall health and bod
systems. Is that okay with you? Great! I will be asking you some questions, ask for simple
commands, and explain what I will be doing. It will roughly take 15-17 minutes. Do you have
any questions?
(Provide privacy, adjust the bed, environmental safety check)
Iwillraiseupthebed,lowerthesiderailsandHOBat45.
2. I know I already asked you for your name and DOB but can you please state it again?
(check wrist band)
3. General Survey: a. Do you know what year it is? 2025
b. Do you know where you are? WCU hospital
c. Do you know why you are here? For your annual check up
d. Do you know who the current president is? Trump
Pt is A&O x4 to person, time, place, and situation. Recent and remote memory intact.
Pt is calm & cooperative, able to speak clearly, appears her stated age, well-groomed, and dressed
appropriately. Responds to questions appropriately. No hearing aids. Able to track and maintain eye
contact. No acute distress noted.
4. Do you have any pain right now? No
If pt was in pain, I will use the PQRST scale. “What makes it worse or better? What does
pain feel like? Where is the pain exactly? Does it spread anywhere? How bad is the pain fro
1-10? When does it occur and how long does it last?”
Head to JVD (hair, skin, eyes, nose, mouth)
1. First, I will inspect your hair and skin.
(separate hair 1” apart at a time, run fingers through scalp)
Hair is evenly distributed, no infestations, no dandruff, no bumps.
(feel temperature of the skin..forehead neck, and press into mandible)
Skin is warm, dry, intact, no scars, lesions, or edema. Skin is appropriate to ethnicity.
2. Now I will inspect your ears.
(check if symmetrical, use penlight, 1” from each ear, pull pinna back inspect ear with penlight, palpate
for any tenderness and ask if patient feels pain or tenderness)
Ears are symmetrical, no signs of redness or drainage in both ears, no lesions or tenderness or
pain when palpated.
3. Next I will inspect your face.
(check for symmetry – facial droop, color (pale, flushed, jaundice)
I can see it’s symmetrical. Skin color is appropriate for ethnicity. No lacerations. Skin integrity
intact. Can you smile and raise eyebrows for me? No facial drooping noted. Can you close your
eyes and tell me which side I’m touching?
Keep your eyes closed and tell me what you smell. Ok its alcohol. Facial sensation and ability
smell intact.
4. Next, I will inspect your eyes.
(ask to remove glasses if any, inspect sclera, and pull down under eyes to see conjunctiva sac)
Eyes are symmetrical, sclera are pearly white. Do you wear glasses or contacts? Okay, Any
issues with vision lately? I’m going to pull down under eyelids. The conjunctiva sac is pink and
moist. No redness and abnormal findings noted.
I am going to dim the lights, please stare straight ahead while I shine a light into your eyes.
