Complete Head to Toe Physical Assessment Script 2023

Complete Head to Toe Physical Assessment Script 2023 1 GENERAL ORDER OF THE EXAM * • Inspect → visually observe pt • Palpate → use hands to feel pt • Percuss → light striking of body parts to produce sounds • Auscultate → listening to body w/stethoscope o Bell = low-pitch sound o Diaphragm = high-pitch sound *All systems except GI 4 CLASSICAL ASSUMPTIONS • A & O x 4 (person, place, time, situation) • Vital signs WNL • Visual acuity assessed via Snellen chart (CN 2 – Optic) • Patient is in NAD PREPARATION • Knock on entry • Introduce yourself o “Hi, my name is Sumiyah, and I’m a nursing student. I will be performing a physical exam on you today.” • Hand hygiene GENERAL SURVEY • Physical Appearance o Age, sex, race/ethnicity • Body Structure o Tall/short o Underweight/overweight/average weight o Proportionality of weight to height • Mobility o Ease in ambulation o Ease in movement of limbs • Behavior/Mood o Response to questions o Grooming/hygiene o Affect/speech/eye contact Ex: “Pt is a (#) y/o (gender ident.) of avg. & proportional height & weight, who moves easily & responds to questions. They are well groomed & have appropriate affect to situation.” SKIN Inspect • Entire body → color, lesion, hair distribution • Finger/Toenails → pitting or clubbing • Describe lesions noting number, location, arrangement & type & document later Palpate (Use the back of the hand) • Moisture, temperature, texture, turgor (pinch back of hand), checking for tenting • Note areas of tenderness or induration “I will continue to inspect the rest of the body bilaterally throughout the remainder of my exam” HEAD → NCAT Inspect • Skull → general size & contour • Scalp → lesions or inhabitants • Hair → quantity, texture, distribution, balding • Face → symmetry (eyebrows, palpebral fissures in line with helices of ears, nasolabial folds) Palpate • Skull → deformities or tenderness • Temporal Artery → induration & intensity (2+ = normal) • TMJ → pain, popping or crepitus (pt. open/close mouth) Neuro Test • CN 7 (Facial - motor) → pt. smile, frown, puff cheeks, resist eye opening • CN 5 (Trigeminal - motor) → pt. clench jaw – masseter muscle engaged • CN 5 (Trigeminal - sensory) → light touch x6 (ask pt. close your eyes & say “now” when you feel it) “Pt is normocephalic – atraumatic” NECK Inspect • Obvious masses or pulsations Palpate • Lymph nodes of head & neck; identify chains → o Preauricular, postauricular, occipital o Tonsillar, submandibular, submental o Anterior cervical, posterior cervical & deep cervical (lean R/L) o Supraclavicular, infraclavicular o Non-palpable or <1cm, mobile, & nontender • Carotids → pulses • Trachea → deviation • Thyroid → size, symmetry, tenderness, consistency, nodules (palpate from behind) Neuro Test • CN 11 – Spinal Accessory (motor) → shrug shoulders, turn head against resistance “CN 2 – 12 are inta