Head to Toe Assessment Script 2024
complete solution
Important information on H to T exam -be cognizant of 1h time frame
-commentary on explain what you're seeing as you do it, pt teaching
-supplies (come wearing uniform, badge, bring johnny, have sheet)
-raise bed to comfortable height
-examining low extremities, be on foot of bed
-set up all supplies in order to help you order your assessment
-at the end can think back and recall any forgotten assessment parts
Supplies -hand sanitizer
-cup of water
-4x pairs of gloves
-2x tongue depressor
-pen torch
-reflex hammer
-stethoscope
-watch
-scents for CN 1 exam
-snellen chart
Introduction:
1. You knock and enter the room. -"Hi, let me check your band"
while...self-intro...
-"I'm B.A. and I'm a student nurse. I will be conducting a head-to-toe assessment on you today to
get an overview of your health."
-"How would you prefer to be called?"
-"Alright Everlyne. How are you today?"
*HAND HYGIENE*
, "thoughout the assesment I will be commenting on my findings, at any point please feel free to
stop me if you have any questions or have any concerns or pain or changes you've noticed you
want to comment on feel free"
Introduction:
2. Look at pt bracelet to verify information... -"Alright I'm going to start by reviewing some
information with you"
-ID:
Full name, DOB, age
-Medication:
Rx, OTC, herbal, vit supplements
*if pt taking med can ask what for and how long
-Allergies:
Medication allergies?
food allergies? environmental/seasonal allergies? latex or IV contrast dye allergies?
Introduction:
3. Done reviewing ID, Meds, Allergies... -"Alright, thank you. Next up I'm going to ask you a
few questions that may seem obvious, but please bear with me"
Evaluate pt mental status:
-person (name)
-place
-date
-"Well done, based on your ability to answer my q's and perform these tasks, I can tell that you're
alert AO x3"
Introduction end:
4. Done evaluating pt mental status... -"Now I'm going to take a full set of vitals, starting with
Temp"
*ELEVATE THE BED TO HEIGHT*
-Temp
-BP (arm at heart height)
-Pulse & Respirations
*report values ALOUD are they in normal range or not? can do 30 sec and x2
5. Full Vitals taken, what do you do next? -Asses the pt exposed SKIN
(face, arms, legs) --> will do feet during pulses exam
-Use back of hand to assess temperature
What factors of the skin assessment should be remarked upon throughout the exam? 1.
color (even skin tone, freckles, noteworthy areas of hyper or hypopigmentation?)
2. temp (warm)
3. texture (smooth)
4. turgor (no tenting)
5. lesions/scars
complete solution
Important information on H to T exam -be cognizant of 1h time frame
-commentary on explain what you're seeing as you do it, pt teaching
-supplies (come wearing uniform, badge, bring johnny, have sheet)
-raise bed to comfortable height
-examining low extremities, be on foot of bed
-set up all supplies in order to help you order your assessment
-at the end can think back and recall any forgotten assessment parts
Supplies -hand sanitizer
-cup of water
-4x pairs of gloves
-2x tongue depressor
-pen torch
-reflex hammer
-stethoscope
-watch
-scents for CN 1 exam
-snellen chart
Introduction:
1. You knock and enter the room. -"Hi, let me check your band"
while...self-intro...
-"I'm B.A. and I'm a student nurse. I will be conducting a head-to-toe assessment on you today to
get an overview of your health."
-"How would you prefer to be called?"
-"Alright Everlyne. How are you today?"
*HAND HYGIENE*
, "thoughout the assesment I will be commenting on my findings, at any point please feel free to
stop me if you have any questions or have any concerns or pain or changes you've noticed you
want to comment on feel free"
Introduction:
2. Look at pt bracelet to verify information... -"Alright I'm going to start by reviewing some
information with you"
-ID:
Full name, DOB, age
-Medication:
Rx, OTC, herbal, vit supplements
*if pt taking med can ask what for and how long
-Allergies:
Medication allergies?
food allergies? environmental/seasonal allergies? latex or IV contrast dye allergies?
Introduction:
3. Done reviewing ID, Meds, Allergies... -"Alright, thank you. Next up I'm going to ask you a
few questions that may seem obvious, but please bear with me"
Evaluate pt mental status:
-person (name)
-place
-date
-"Well done, based on your ability to answer my q's and perform these tasks, I can tell that you're
alert AO x3"
Introduction end:
4. Done evaluating pt mental status... -"Now I'm going to take a full set of vitals, starting with
Temp"
*ELEVATE THE BED TO HEIGHT*
-Temp
-BP (arm at heart height)
-Pulse & Respirations
*report values ALOUD are they in normal range or not? can do 30 sec and x2
5. Full Vitals taken, what do you do next? -Asses the pt exposed SKIN
(face, arms, legs) --> will do feet during pulses exam
-Use back of hand to assess temperature
What factors of the skin assessment should be remarked upon throughout the exam? 1.
color (even skin tone, freckles, noteworthy areas of hyper or hypopigmentation?)
2. temp (warm)
3. texture (smooth)
4. turgor (no tenting)
5. lesions/scars
