Head to Toe Script

(bold you would say)

*Knock on the door, open the door, and provide privacy

Hello, Mrs./Mr. _____, my name is _____ and I’m a student nurse. I’ll be
helping out your nurse to take care of you today. Is that alright?

Great. I’m just going to wash my hands over here and then I’ll just take a
listen to your heart, lungs, and abdomen and see how you’re doing today.

(Wash your hands)

I have just a few routine questions I need to ask before we get started.
They’ll help me take the best care of you that I can.

Can you tell me what day of the week it is? (Establishes that they are alert
and oriented (A&O) to time)
Great, can you tell me where you are? (Establishes that they are alert and
oriented (A&O) to place)
Wonderful. So what brought you here? (Establishes that they are alert and
oriented (A&O) to the situation)

By now you will be finished washing your hands. Put on gloves. Walk over
to their bed and take a look at their name bracelet.

And can you tell me your name and date of birth please (Establishes that
they are alert and oriented (A&O) to person)

Are you in any pain at all right now?

Do you use anything to get around, like a walker, wheelchair, or

cane?

Are you able to do things like cook, bathe, brush your hair, and brush
your teeth? Or do you usually have someone help you with that?

Great, thank you for answering my questions. I am going to look you over a
bit and see how you are doing and listen to your heart, lungs, and
abdomen. I will keep you covered as much as I can, and please let me know
if you have any new pain at all during this process.
Physical Assessment

Head:
I’ll start at your head up here.
Feel their head for symmetry, shape, lumps, bumps, and bruises. Inspect their
hair, and note the color, amount and distribution. Take a look at their face to look
for symmetry and any missing facial features.
Head is symmetrical and clear of any bumps, lumps or bruises. Hair is
equally distributed and clean.

Eyes:
Now I’m going to take a peek into your eyes. Do you wear contacts or
glasses?
I’m just going to pull down your eyelids a bit here.
Gently pull down their eyelids and look at their conjunctiva. Note the color and if it
is moist or dry.
Conjunctiva is white, no signs of drainage or redness.

Now I’m going to make sure your pupils are doing what they should be
doing. So I have a little light here and I’m going to shine it twice into each
eye. (This checks for pupil constriction and consensual constriction)
Now, can you focus on my penlight as I bring it to your nose? (This checks
for accommodation)
Please note: Pupil constriction, consensual constriction, and accommodation
gives you PERRLA
Pupils are equal, round, reactive to light, and accommodation)

Ears:
Now I’m going to take a peek into your ears.
Do you wear hearing aids?
Check their ears to make sure there is no redness or discharge, and that the skin
is intact (especially if they are on oxygen, which can cause skin breakdown
behind the ears).
Ears are free of discharge, no redness or skin break down.
Mouth:
Can you open your mouth for me please?
Shine your penlight to take a look at their cheeks, gums, tongue, and throat. Note
if it is red, swollen, patchy, or anything else that’s not the normal “pink and
moist.”
Mouth is moist, teeth are intact, tongue is pinky red. No swollen areas or
patchy areas.

Nose:
Take a look at their nose to check for symmetry.
Do you have a runny nose or are feeling stuffy at all?
I’m just going to take a quick look inside your nose. Check for discharge,
redness, or anything abnormal.
Nose is symmetrical, no signs of drainage or skin breakdown.

Neck:
Now I’m going to feel your neck. Please let me know if you feel any
discomfort or pain.
Palpate around their neck, check for swelling, tenderness, or pain.
Can you move your head to the right for me? Now to the left? Now up, and
down? Did that cause any pain or discomfort at all?
I’m going feel your collar bone here. Gently check for skin turgor by gathering
a little bit of skin between your thumb and index finger, right below their collar
bone.
Neck is symmetrical, trachea is midline. No JVD present. Neck mobility is
symmetrical on both sides.
Skin turgor indicates good hydration status.

Arms and Fingernails

I’m going to feel your arms now.
Gently feel their arms all the way down to their hands. Note any swelling that is
present. Feel their radial pulses on both wrists, and note if the pulses are
thready, weak, strong, or bounding, and if they are happening at the same time
or not.
Check their fingernails for hygiene and nutrition (clean, trimmed, smooth, clear)
and gently press on their fingernails to check for capillary refill.
Radial pulses 2+ on both sides. Arms are warm to the touch, no areas of
swelling or skin breakdown. Fingernails are clean. Capillary refill within 2
seconds on each finger.
Lungs:
Have you been coughing at all lately?
I’m just going to pull down your gown a
little here, I’ll keep you covered as
much as possible.
Inspect their chest for symmetry and
shape, and note the size of their costal
angle.
Chest is symmetrical on inhalation and
exhalation, no accessory muscle use is
present.
Now I’m going to take a listen to your
lungs. I’ll move my stethoscope to
multiple places so that I can get a really
good listen.

Each time you move your stethoscope to a new place, ask your patient: Please
take a deep breath in, and out through your mouth.
Listen for a full respiratory cycle at each site. Note their breathing rhythm, effort
and depth, as well as if their rib cage is moving symmetrically.
I listened to your lungs in the front first in all 12 quadrants and each had
clear breath sounds. No strenuous effort present, rhythm and depth equal.

I’ll need to listen to your lungs on your

back as well. Do you need sitting up?

While I am here I am looking at your

spine and back as well. Spine is
symmetrical. No signs of skin
breakdown across their back or bottom.
Skin is warm.
I listened to your lungs in the back in all
12 quadrants and each had clear breath
sounds with equal rhythm and depth.

Alright, now let’s lie you back down.

Heart:
I’m going to listen to your heart now. You can
just relax and breathe normally.

Remember the mnemonic “A P E T Monkey”

Aoritic Pulmonic Erbs point Triscuspid Mitral”
“Aortic: found right of the sternal border in the 2nd intercostal space “

“Pulmonic: found left of the sternal border in the 2nd intercostal space”

Erb’s Point: found left of the sternal border in the 3rd intercostal space”

Tricuspid: found left of the sternal border in the 4th intercostal space”

Mitral: found left of the sternal border at the midclavicular in the 5th intercostal
space”

Abdomen:
Now I’m going to take a look and a listen to your tummy. I’ll just pull up
your gown a little bit here, but I will keep you covered as much as
possible. (Keep their bikini area covered with blankets and pull up their gown
enough to see their belly).
Is your belly tender at all?
Make sure to follow the correct assessment order when doing your abdominal
assessment (inspect, auscultation, percussion, palpation).
Look at their belly first. Then listen with your stethoscope for 15 seconds in each
quadrant. Then percuss with your fingers. And lastly, palpate by pressing lightly
around their belly.
I am inspecting your abdomen first looking for any areas that are pulsing or
raised. I don’t see any areas of concern so will move on to auscultation

I am going to listen to your stomach in all 4 quadrants.

Upper Right (listen)…… bowel sounds present…..Upper Left (listen)……
bowel sounds present…..Lower left…….. (listen) bowel sounds
present…..Lower Right (listen) …….bowel sounds present

I am going to lightly percuss your abdomen now. Percussion is done to

discover any areas that might be filled with gas or air.
One hand over the other lightly tap with hand on top (done with 2 fingers)
I am going to lightly palpate now let me know if there is any areas of
tenderness. With 2 fingers lightly move in a circle in all 4 quadrants for a few
seconds.
No areas of tenderness or guarding noted.
Move their gown back down.
When was the last time you had a bowel movement? Was it difficult to
pass? What was the consistency and color?

Legs, Feet and Toenails:

Now I’m going to take a look at your legs and your feet.
Do you have any pain or discomfort in your legs or feet right now?
Palpate down their legs. Note if their skin is intact, if there are any bruises or
swelling, if their leg hair is patchy or evenly distributed, and if you can see their
veins.
Legs are free from swelling and warm to the touch. Leg hair is evenly
distributed. Antecubital pulses are equal on both legs.
Check their toenails for hygiene and nutrition (clean, trimmed, smooth, clear) and
gently press on their toenails to check for capillary refill.
Toes are clean. Capillary refill is within 2 seconds on each toe. No signs of
edema on heels.
Feel their dorsalis pedis pulses at the same time (one on each foot) and their
posterior tibialis pulses at the same time (one on each foot). Note if it is thready,
weak, strong, or bounding.
Dorsalis Pedis are equal on both sides.
Cover their legs back up.

Muscles:
I am going to have you hold my hands. I am going to push against you and
I want you to try to push me back…..great, equal strength noted when I
push against you

Now I am going to pull you towards me and I want you to pull away……
great, equal strength noted when I pull against you.

I am going to monitor your gait now (pretending) I am going to have you get
up slowly and give me a urine sample in the bathroom. (pretending) Can you
dangle your legs for a little bit….do you feel dizzy? Okay I will help you get
up. (pretending)

Patient is walking to the bathroom and their gait is well balanced, no

limping

Urinary:
Thank you for providing the urine sample for me. I am looking and it is
clear consistency, no particles or blood. Hay yellow colored. I will
document my findings.

Cranial Nerves:
Olfactory Nerve: “Can you close your eyes and tell me what you smell (put
alcohol wipe under nose)

Optic Nerve: “I am going to test your visual acuity with the Snellen chart.
Can you close one eye and read line 4 for me? Great thank you, can you
repeat with the other eye? Great thank you. Visual acuity 20/20”

Oculomotor, Trochlear, and Abducens Nerves: “I am going to test your

eyes with 3 of the cranial nerves now”

 Pupillary light reflex: “can you look straight ahead for me, I am going
to shine my pen light into your eye from the side to look at your
pupils response”
o Shine a pen light into each eye, bringing the beam in quickly from
the lateral side
o Observe response

“Pupils reacted to the light equally.”

 Pupillary accommodation: “I am looking at your pupils ability to

accommodate now. Can you look at my finger please? I am going to
slowly bring it closer to you and am looking to see your pupils
accommodate to the closer distance.

“This is monitoring also for nystagmus which is not present”

o Watch the pupils for equal convergence and constriction

 Ocular movements “Can you keep your head still and follow my
finger”
o Ask the patient to keep their head still and follow your finger
o Move the object around in an H formation, assessing both horizontal
and vertical gaze

Trigeminal Nerve “I need you to close your eyes again for this next cranial
nerve test. I have a cotton swab here with the cotton tip and then wooden
base. The cotton tip is soft, the wooden base is like a pin prick. I am going
to touch various areas of your face gently with either side and I’ll ask you
to please tell me which area I touched and which side I used”
 o Demonstrate to the patient what to expect from the light touch and
pin prick sensations
o Ask the patient to close their eyes and gently touch the forehead,
cheeks, and chin regions with soft or sharp

“Thank you, I am now going to check your motor function of the trigeminal
nerve by having you clench your jaw shut….thank you can you now move
your jaw to the left…..now the right….great!”

 Motor function is checked by the muscles of mastication

o Ask the patient to clench their teeth tight and palpate for the
contraction in the temporalis muscle and masseter muscle
o Ask the patient to open their mouth, move their jaw from side to side,
then close their mouth

Facial Nerve “I am moving on to the facial nerve now. Face is symmetrical

at rest…. Can you raise your eyebrows….smile…..close your eyes
tightly….puff out your cheeks….great! All movements were easily
preformed and symmetrical”

Vestibulocochlear Nerve “now we are testing your hearing. I am going to

whisper a number into each of your ears separately and have you repeat
what number I said…..(walk to left side and whisper a number) (patient repeats)
(repeat on right side) thank you!

Glossopharyngeal and Vagus Nerves “I am going to test IX and X together.

Can you please cough for me….great thank you. Can you say
ahhhhhh….great thank you. The soft palate moved upwards on
visualization”

Accessory Nerve: “I am going to gently place my hand against your cheek

and would like you to turn your head from side to side against my
resistance. (hand against left side have patient turn to left) (repeat with right)

“Great now I am going to put my hands on your shoulders and have

you shrug up against me”

 Sternocleidomastoid can be assessed by asking the patient to turn their

head to each side, against the examiners resistance
 Trapezius can be assessed by asking the patient to shrug their shoulders,
against the examiners resistance
Hypoglossal Nerve: for this last nerve I am going to have you stick out your
tongue. Can you move it from side to side for me…thank you”

Finishing Up:
Alrighty, we are all done. Thanks so much for your patience.

Make sure the bed is in the lowest position, it’s locked, the rails are up or down
(depending on their safety plan), and that their call light is within reach.

Is there anything I can get for you?

Alright. I will be back in later. You can use your call light if you need
anything sooner.

Wash your hands.