Head to Toe Script
AIDET
Hi my name is… and I will be your student nurse today.
Can you please state your name and date of birth?
Before we begin, can you tell me if you are in any pain on a scale from 0-10?
Any allergies? yes, iodine
Okay , the reason I am here is to perform a complete head-to-toe
assessment on you. It’s gonna take me about 25-30 minutes. Is now a good
time? Now, while I am doing this assessment, I will be asking personal
questions and also touching you in certain private areas throughout this
assessment. Do I have your permission to continue? Provide privacy
Cognitive Assessment, General
Appearance, Gait
Can you tell me what brought you in today?
Can you tell me what day of the week it is?
What did you have for breakfast this morning?
I am going to give you 4 words to remember and later I am going to ask you
to repeat these 4 words. The words are truck, house, spoon, and yellow.
5 minutes have passed can you repeat those 4 words back to me?
Pts long and short-term memory are intact, pt is alert and oriented
x4
I am going to need a urine sample. Are you able to provide one?
Pt presents with normal gait, ambulation, and balance and can
follow simple commands.
The restroom is down the hall to the right.
, As the patient is walking I am observing her gait, ambulation, and
balance. As the patient returns I am observing the patients
appearance I note the patient is dressed appropriately for the
occasion.
HAND HYGIENE AND APPLY GLOVES
GU
Thank you for your sample I will now COACH your urine.
Urine is yellow, odorless, no sediment or particulate matter present,
warm to the touch, and 30 mL.
While giving this sample, did you have any burning, itching, or hesitancy?
Pt states no abnormalities with urination
Do you have any history with frequent UTIs?
No history of frequent UTIs.
When was your last menstrual cycle?
Do you do monthly breast-self exams?
When was your last testicular exam?
HAND HYGIENE AND APPLY GLOVES
Muskuloskeletal and ROM
While you are standing, I would like to check your cervical spine. I am going
to be inspecting, palpating, and assessing your range of motion.
First can you tuck your chin to your chest, look straight
Spine present straight, has normal curvature. The back is
symmetrical and well in its muscle mass. No signs of protrusions,
deformities, or other abnormalities. ROM is good
Bring your ears to your shoulder
Can you bend over to touch your toes
AIDET
Hi my name is… and I will be your student nurse today.
Can you please state your name and date of birth?
Before we begin, can you tell me if you are in any pain on a scale from 0-10?
Any allergies? yes, iodine
Okay , the reason I am here is to perform a complete head-to-toe
assessment on you. It’s gonna take me about 25-30 minutes. Is now a good
time? Now, while I am doing this assessment, I will be asking personal
questions and also touching you in certain private areas throughout this
assessment. Do I have your permission to continue? Provide privacy
Cognitive Assessment, General
Appearance, Gait
Can you tell me what brought you in today?
Can you tell me what day of the week it is?
What did you have for breakfast this morning?
I am going to give you 4 words to remember and later I am going to ask you
to repeat these 4 words. The words are truck, house, spoon, and yellow.
5 minutes have passed can you repeat those 4 words back to me?
Pts long and short-term memory are intact, pt is alert and oriented
x4
I am going to need a urine sample. Are you able to provide one?
Pt presents with normal gait, ambulation, and balance and can
follow simple commands.
The restroom is down the hall to the right.
, As the patient is walking I am observing her gait, ambulation, and
balance. As the patient returns I am observing the patients
appearance I note the patient is dressed appropriately for the
occasion.
HAND HYGIENE AND APPLY GLOVES
GU
Thank you for your sample I will now COACH your urine.
Urine is yellow, odorless, no sediment or particulate matter present,
warm to the touch, and 30 mL.
While giving this sample, did you have any burning, itching, or hesitancy?
Pt states no abnormalities with urination
Do you have any history with frequent UTIs?
No history of frequent UTIs.
When was your last menstrual cycle?
Do you do monthly breast-self exams?
When was your last testicular exam?
HAND HYGIENE AND APPLY GLOVES
Muskuloskeletal and ROM
While you are standing, I would like to check your cervical spine. I am going
to be inspecting, palpating, and assessing your range of motion.
First can you tuck your chin to your chest, look straight
Spine present straight, has normal curvature. The back is
symmetrical and well in its muscle mass. No signs of protrusions,
deformities, or other abnormalities. ROM is good
Bring your ears to your shoulder
Can you bend over to touch your toes
