NR302: HEALTH ASSESSMENT/HEAD TO CHEST RETURN DEMONSTRATION
INTRODUCTION: 4. Client’s skin turgor appears normal. No skin tenting
is noted and there is immediate recoil.
1. Knock on door
2. Pull curtain **I am now going to assess client’s nails**
3. Sanitizer
4. Raise bed to hip level , and lower bed rail. 5. Client’s nailbeds appear pink, smooth even and
5. Hello Mr. Smith, my name is Nicole and I will be curved at a normal 160 angle.
your student nurse today. I am here to get a baseline
of your health by doing a head to chest assessment. **I will now assess client’s capillary refill by pressing on his
The assessment will involve me examining you and nail for 5 seconds and release**
may involve some touching.
6. Do I have your consent to continue? 6. Client’s capillary refill shows normal color return in
7. Can you please verify your name and DOB? less than 2 seconds.
8. Do you have any allergies to food, medication or
latex? HEAD, FACE & NECK:
PAIN: **I am now going to inspect client’s face, head and neck
(DON gloves)**
1. Are you having any pain today?
2. Where is your pain located? 1. The client’s facial features appear symmetrical.
3. How would you rate your pain on a scale of 0-10? 2. There are no infestations or lesions noted on the
4. What does the pain feel like? Stabbing? Pressure? client’s head.
5. Is the pain constant or does it come and go? 3. Client’s trachea appears midline with no palpable
6. Does the pain stay in one spot or does it radiate to masses.
other areas?
7. When did the pain begin? EYES:
8. What makes your pain better? What makes your
pain worse? **I am now going to inspect the external ocular structures**
9. What does the pain mean to you?
1. There is no redness or discharge noted.
GENERAL SURVEY:
**I am going to assess the client’s sclera and conjunctiva
1. Client does not show any signs of acute distress. (DON gloves & pull down eyelid)**
2. Client appears calm, cooperative and expression is
appropriate to situation. 2. The client’s conjunctiva is clear and pink; the sclera
3. Client’s speech is clear and coherent. is white with no visual abnormalities.
**I am going to assess client’s LOC: What’s your name? **I am now going to assess the client’s pupils (DON gloves,
Where are you? What year is it? Do you know why DIM lights, USE penlight to measure)**
you’re in the hospital?**
3. Client’s pupils appear normal size at 3mm and
4. Client is alert and oriented to person, place, time and pupils are equal, round and reactive bilaterally.
situation.
**I am now going to assess the client’s pupils for light
SKIN & NAILS: reactivity**
**I am now going to assess the client’s skin and nails** **Instruct client to look straight ahead and wave penlight**
1. Client’s skin is warm, dry and intact. 4. Client’s pupils are constricting consensually (say
2. Client’s skin color is appropriate to ethnic this twice)
background.
3. There are no visible wounds, lesions or incisions. **I am now going to assess client’s pupils for
accommodation (Instruct client to follow penlight far and
**I am going to gently pinch client’s clavicle skin to assess near) **
skin turgor**
INTRODUCTION: 4. Client’s skin turgor appears normal. No skin tenting
is noted and there is immediate recoil.
1. Knock on door
2. Pull curtain **I am now going to assess client’s nails**
3. Sanitizer
4. Raise bed to hip level , and lower bed rail. 5. Client’s nailbeds appear pink, smooth even and
5. Hello Mr. Smith, my name is Nicole and I will be curved at a normal 160 angle.
your student nurse today. I am here to get a baseline
of your health by doing a head to chest assessment. **I will now assess client’s capillary refill by pressing on his
The assessment will involve me examining you and nail for 5 seconds and release**
may involve some touching.
6. Do I have your consent to continue? 6. Client’s capillary refill shows normal color return in
7. Can you please verify your name and DOB? less than 2 seconds.
8. Do you have any allergies to food, medication or
latex? HEAD, FACE & NECK:
PAIN: **I am now going to inspect client’s face, head and neck
(DON gloves)**
1. Are you having any pain today?
2. Where is your pain located? 1. The client’s facial features appear symmetrical.
3. How would you rate your pain on a scale of 0-10? 2. There are no infestations or lesions noted on the
4. What does the pain feel like? Stabbing? Pressure? client’s head.
5. Is the pain constant or does it come and go? 3. Client’s trachea appears midline with no palpable
6. Does the pain stay in one spot or does it radiate to masses.
other areas?
7. When did the pain begin? EYES:
8. What makes your pain better? What makes your
pain worse? **I am now going to inspect the external ocular structures**
9. What does the pain mean to you?
1. There is no redness or discharge noted.
GENERAL SURVEY:
**I am going to assess the client’s sclera and conjunctiva
1. Client does not show any signs of acute distress. (DON gloves & pull down eyelid)**
2. Client appears calm, cooperative and expression is
appropriate to situation. 2. The client’s conjunctiva is clear and pink; the sclera
3. Client’s speech is clear and coherent. is white with no visual abnormalities.
**I am going to assess client’s LOC: What’s your name? **I am now going to assess the client’s pupils (DON gloves,
Where are you? What year is it? Do you know why DIM lights, USE penlight to measure)**
you’re in the hospital?**
3. Client’s pupils appear normal size at 3mm and
4. Client is alert and oriented to person, place, time and pupils are equal, round and reactive bilaterally.
situation.
**I am now going to assess the client’s pupils for light
SKIN & NAILS: reactivity**
**I am now going to assess the client’s skin and nails** **Instruct client to look straight ahead and wave penlight**
1. Client’s skin is warm, dry and intact. 4. Client’s pupils are constricting consensually (say
2. Client’s skin color is appropriate to ethnic this twice)
background.
3. There are no visible wounds, lesions or incisions. **I am now going to assess client’s pupils for
accommodation (Instruct client to follow penlight far and
**I am going to gently pinch client’s clavicle skin to assess near) **
skin turgor**
