NR 304 Health Assessment II Head to Toe Assessment Final Script

NR 304 – Health Assessment II Head to Toe Assessment Final Script Introduction & AIDET ***Knock Knock*** Me: May I come in? Patient: Yes. Me: Hi, my name is (insert name) and I am a student nurse at Chamberlain University, and I have physician’s orders to perform a head to toe assessment on you which will take about 15-20 minutes, is now a good time? Patient: Yes. Me: I am going to start off with providing you with some privacy by closing off these curtains and taking care of my hand hygiene.  close curtains  perform hand hygiene  put on gloves Me: Can I get your name and date of birth please? Patient: (Patient Name); June 27, 1999 Me: Okay, let me just check your wristband to verify.  check wristband Guadalupe Jaime, June 27, 1999 Okay Ms. Jaime, are you allergic to any: food, medications shellfish iodine/betadine, latex, tapes or any other adhesives? Patient: No. Me: And are you in any pain today? Patient: No. Me: Okay, do you know where you are Ms. Jaime? Patient: Chamberlain University Me: Okay, do you know what year it is? Patient 2019 Me: And do you know who our current president is? Patient: Donald Trump Me: Patient is alert and oriented (x4) Speech is clear and clothing is appropriate to time and place. General Appearance Me: Okay, we’re gonna go ahead and move on to your general appearance.  look at the patient Posture is erect. Skin is appropriate to age. Skin color is appropriate to ethnicity. No signs of acute distress. Nutrition is adequate. Mood and behavior are appropriate to situation. And clothing is appropriate to situation as well. (No visible devices or equipment being used.) Vital Signs Me: I will now be taking your vital signs.  check temperature o before checking the temp, ask if patient had anything hot or cold to drink, or smoked in the last 30 mins  check the pulse oximetry  take the blood pressure o ask if patient knows their usual blood pressure measurement  check respirations o count for 30 seconds and multiple by 2 Skin & Nails Me: I’m gonna go ahead and start with your skin. Skin color is appropriate to ethnicity. There are no signs of lesions, incisions, wounds, rashes, and no tattoos visible. I’m gonna go ahead and check for your temperature.  palpate skin using the back of the hand Skin is warm to touch. I’m gonna go ahead and pinch your clavicle.  pinch clavicle to check skin turgor There are no signs of tenting or dehydration. I’m gonna go ahead and move on to your nails.  pick up patient’s hands and assess nails Nails are round, nail beds are pink, contour is normal. I’m gonna go ahead and check for capillary refill.  perform capillary refill by pinching each finger on both hands Capillary refill is less than 2 seconds. Head & Face Me: Okay, I’m gonna go ahead and ass