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NR 304 – Health Assessment II Head
to Toe Assessment Final Script
Introduction & AIDET
***Knock Knock***
Me: May I come in?
Client: 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?
Client: 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?
Client: (Client 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?
Client: No.
Me: And are you in any pain today?
Client: No.
TOPNURS MAY-AUGUST 2023/2024
,Me: Okay, do you know where you are Ms. Jaime?
TOPNURS MAY-AUGUST 2023/2024
, Client: Chamberlain University
Me: Okay, do you know what year it is?
Client 2019
Me: And do you know who our current president is?
Client: Donald Trump
Me: Client 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 client
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 client 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 client 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.
TOPNURS MAY-AUGUST 2023/2024
NR 304 – Health Assessment II Head
to Toe Assessment Final Script
Introduction & AIDET
***Knock Knock***
Me: May I come in?
Client: 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?
Client: 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?
Client: (Client 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?
Client: No.
Me: And are you in any pain today?
Client: No.
TOPNURS MAY-AUGUST 2023/2024
,Me: Okay, do you know where you are Ms. Jaime?
TOPNURS MAY-AUGUST 2023/2024
, Client: Chamberlain University
Me: Okay, do you know what year it is?
Client 2019
Me: And do you know who our current president is?
Client: Donald Trump
Me: Client 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 client
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 client 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 client 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.
TOPNURS MAY-AUGUST 2023/2024
