Head to Toe Assessment Script

1. Knock on door. “Hello, my name is Leslie, I’m your nurse for today. I am going to be doing a head-to-toe assessment on you. It’s going to take about 10 minutes.” 2. “First let me pull the curtain for your privacy.” Pulls imaginary curtain. 3. “Going to wash my hands.” Pulls hand sanitizer on. 4. “Can you tell me your name and date of birth.” (Patient responds) 5. “Okay, let me check your wrist.” Checks imaginary arm band. 6. “Can you tell me where you are?” (Patient responds) “And do you know todays date?” ( Patient responds ) “Patient is alert and oriented x3. Speech is clear, hygiene is appropriate, and posture is good and relaxed. Are you comfortable? (Patient responds) 7. “So first I’m going to have you close your eyes and tell me where I am touching your face.” Touch forehead, nose, left cheek and right cheek. “Okay open your eyes, can you smile? Frown. Puff your cheeks. Raise your eyebrows. Cranial nerves 5 & 7 are intact.” 8. “I am going to inspect your head, tell me if you have any tenderness.” Palpate around the head. “Does that hurt?” (Patient responds) “No parasites, bumps, lesions, no tenderness. And hair is appropriate for age and family history.” 9. “So I am going to look in your eyes.” Looks at eyes. “No redness or drainage.” - “I am going to shine a light into your eyes. Could you just look straight ahead.” Starting with their right eye, shine light from under to the eye and the same for the left eye. - “Look at the top, and follow with your eyes.” Midline put the pen close to their nose and then back out. “Pupils are equal, round, reactive to light and accommodate.” 10. “So next I am going to have you follow just with your eyes the top of my pen and do not move your head. Midline move the pen up and down, up to the left diagonal then to the left, then down, then to the right diagonal and then to the right. “Cranial nerves 3, 4 and 6 are intact.” 11. “Now we are going to do confrontation test. So cover your right eye and tell me how many fingers you see.” Two fingers, from middle, top and bottom. “Okay, next eye.” Two fingers, from middle, top and bottom. “Cranial nerve 2 is intact. You can uncover your eye now.” 12. “Now I am going to look into your mouth. Can you open your mouth for me.” Shine light into the mouth. “Muscosa is pink and moist. Can you stick out your tongue and say ahh.” “Uvula and midline are midline.” - Using the dorsal side of the hand place it in front of the neck. “Okay swallow” “Cranial nerves 9, 10, and 12 are intact.” 13. “Now I am going to look into your nose.” Shine the light into both nostrils “No drainage, no deviation.” “Can you close one nostril and breathe in? Now the other.” “Nostrils are patent.” 14. “Now I am going to look into your ears.” Look inside both ears. “No excessive cerumen, no drainage, no lesions.”