538 - Unintentional ASMR - Assessment / Exam / Head to Toe

Added: 2026-05-14

[00:00:01]Hi. Hello.

[00:00:03]My name is Taija, and I'm going to be your nurse today. How are you? Good, thank you.

[00:00:07]That's good. So, today we're going to be doing a quick head-to-toe assessment.

[00:00:11]Before we get into that, could I get your first and last name, please? Yeah, it's uh Millie Larson. And your date of birth? 12/14/49.

[00:00:19]And do you have any allergies? No allergies. Okay, and I'm just going to check that against my chart with your wristband. Great.

[00:00:27]And I am going to ask you a few questions. Um could you tell me where you are right now? Yeah, uh Concordia Hospital. Yes, and what day it is? Um today is June 11th, 2024. Okay, and what brings you in? Um I My ankle hurts. Your ankle? Okay, so you have some ankle pain.

[00:00:45]All righty.

[00:00:47]So, we're going to do a head-to-toe assessment. Um it's going to be about 15 minutes, and we're just going to check all the different regions of your body, especially that ankle pain. And we're going to take that information and give it to the provider after, okay? Okay. As for that ankle pain, um could you tell me a little bit more about it? When did it start? Uh last Thursday, I was gardening, there was a root, and I tripped. Okay, and you said your ankle, could you point to the area? Yeah, like Your right ankle? Okay. And if you were to rate that pain, zero being no pain at all, and 10 being the worst, how would you rate it? Like a three. A three?

[00:01:18]Okay. And is there anything that makes that pain worse? Yeah, when I'm like walking and moving around. Okay, and if you were to rate that from zero to 10, with 10 being the worst?

[00:01:26]>> Like a five.

[00:01:27]>> A five? Okay. And is there anything that makes that pain better?

[00:01:30]Just kind of resting.

[00:01:31]>> Resting? So, sitting down like right now, that's better? Yeah, that feels good. Okay, and could you describe the pain, like what type of pain it is? Mm achy. When I walk, maybe a little throbbing. A little throbbing? Okay. And you did say it started yesterday? Uh yeah. Yesterday? Okay. And do you have any goals for your pain that you would like to reach? Just like no pain. No pain? And is it tolerable at a three out of 10? Yeah, that's tolerable.

[00:01:55]Tolerable? Okay. Well, our goal is to try to decrease that pain, so we're going to use our head to toe assessment to find information for that. Okay. So, I'm just going to come in front of you for like a second. Mhm. The patient has no involuntary movement. The patient's speech is not slurred and is appropriate. The patient's face is symmetrical. So, with our head to toe assessment, I'm going to start at your head. I'm going to inspect and then palpate and touch different regions of your body, okay? Okay. And do you give me permission to go ahead and touch you?

[00:02:21]>> Yes, of course.

[00:02:23]So, inspect, I don't see the head is symmetrical.

[00:02:27]Patient's hair is thick and has no signs of alopecia. No lice or phony.

[00:02:32]The patient's skin behind the neck is intact.

[00:02:37]I'm not sure if I said it, but just to clarify, you were alert and oriented times four, okay? Okay. Perfect. And then I'm going to check your temporal pulses, which is right here on your forehead.

[00:02:47]Temporal pulses are plus two bilateral and regular. I'm also next going to check your sclera and your conjunctiva.

[00:02:54]So, I'm just going to look at you. The patient's sclera is white. I'm pulling down on with my thumbs.

[00:03:00]Patient's conjunctiva is pink. Now, I'm going to use my pen to check inside of your ears, okay? Okay. Starting on the left side.

[00:03:10]There is no drainage on the left ear, no signs of masses or lesions, and the skin is intact behind the ear.

[00:03:19]As for the right side, there's no signs of drainage, masses, or lesions, and the skin is intact behind the ear. Now, I'm going to also check your eyes. First, we're going to start with something called the six cardinal fields of gaze.

[00:03:29]You're just going to look at the tip of this pen, keep your head as straight as possible, and just follow the pen, okay?

[00:03:34]Okay.

[00:03:41]Okay, and just keep looking at the point. Keep your head straight.

[00:03:46]All righty. Now, I'm going to measure your pupil size.

[00:03:54]The patient's pupil sizes is 3 mm and now I'm going to test your pupils reaction to light.

[00:04:00]So, just look straight behind my ear.

[00:04:07]Okay. So, the patient's eyes are appropriate. The pupils are equal, round, and reacted to light and accommodation. I'm also going to go ahead and use this light to check the side of your nostrils. If you could tilt your head up.

[00:04:22]Patient's nasal mucosa is pink with no signs of drainage and is intact. I'm also going to check within your mouth.

[00:04:27]If you can open up and say ah. Stick your tongue out.

[00:04:33]Thank you. The patient's oral mucosa is pink. There's no signs of lesions. The tongue is also pink with no lesions or deformities. Um and the patient's teeth are intact. Um quick question, for your teeth, do you wear any dentures?

[00:04:47]>> No dentures. They're all mine. Okay. And do you ever have any trouble coughing or any sputum production?

[00:04:52]>> No. No? And do you ever have any trouble swallowing? No. Okay. And then back up to your eyes. Do you wear any contacts or glasses? Do you ever have any trouble seeing at all? No? And then for your ears, do you ever have any trouble hearing anyone? Do you wear any assistive devices like a cochlear implant?

[00:05:10]>> No. No? Okay. So, the patient's hearing and vision is adequate. Um we're going to check your swallowing. If you could just go ahead and give me a quick swallow.

[00:05:19]Okay. The patient's swallowing is adequate and uh there's no tracheal deviation. I'm also going to check your pulses right under your neck. These are the carotid pulses.

[00:05:34]Patient's carotid pulses are plus two bilaterally, equal and regular. I'm also going to check your skin turgor, which is going to be a light little pinch at your midclavicular line, okay?

[00:05:46]The patient's skin now shows signs of tenting. Um the patient's uh skin is appropriate to ethnicity. The patient's skin is warm and dry. I'm also going to move down now to your upper extremities.

[00:05:58]I'm just going to check your arms.

[00:06:01]And if you could turn.

[00:06:03]Okay.

[00:06:05]Patient's skin is warm.

[00:06:08]And can you feel this? Mhm. Okay, the patient's sensation of the upper extremities is appropriate and adequate.

[00:06:14]I'm going to check your brachial pulses, which are going to be in this part of the arm.

[00:06:24]Patient's brachial pulses are plus two regular and equal and bilateral. Now I'm going to go down and also check your radial pulses, which are at your thumb line.

[00:06:36]Oh, these pulses are strong. Patient's radial pulses are plus two equal, bilateral, and regular. Um the patient's skin of the upper extremities is appropriate to ethnicity. It is also warm and dry, and the patient's skin seems to be hydrated. No signs of dehydration. So now I'll move down to your hands and check your capillary refill for each 10 digits.

[00:06:56]So yeah, just move your fingers.

[00:07:06]The patient's capillary refill in the digits is less than three uh seconds. Um now I'm also going to check the strength of your hands, okay? So if you could just push against my hands with yours.

[00:07:16]Great. And if you could pull. Great. And then if you could squeeze as hard as you could. Great. The patient's uh strength in the upper extremities is a five out of five. Now we're going to test your range of motion. So if you could go ahead and flex your arms this way.

[00:07:30]Great. And then while we're looking, patient's skin is intact at the elbows.

[00:07:34]And then extend them forward. And then bring them parallel to your body. And let's just rotate your shoulders. Great.

[00:07:40]The patient has full range of motion in upper extremities.

[00:07:44]Um I'm now going to go ahead and listen to your lung sounds. Um you's going to be six points in the front and eight points in the back, okay? Um the patient's chest is symmetrical and it seems to be equal chest rise and fall.

[00:07:57]And then check your chest rise and fall from here. Just breathe normally.

[00:08:01]Patient has chest rise and fall equal and bilateral, both anterior and posterior.

[00:08:06]And I'm just going to start listening.

[00:08:08]Um if you ever feel any dizziness or you know, drowsiness or anything, just go ahead and let me know and I'm going to coach you with a deep breath in and out, okay?

[00:08:22]Okay, so we're going to start right here. In.

[00:08:26]Out.

[00:08:28]In.

[00:08:30]Out.

[00:08:32]In.

[00:08:34]Out.

[00:08:36]In.

[00:08:41]Right here. In.

[00:08:43]Out.

[00:08:45]In.

[00:08:47]Out. And now we're going to switch to your back. You can lift your arms. Thank you.

[00:08:52]Go ahead. In.

[00:08:55]Out.

[00:08:57]In.

[00:09:01]In.

[00:09:04]In.

[00:09:08]In.

[00:09:12]In.

[00:09:16]In.

[00:09:17]And last one.

[00:09:20]In.

[00:09:24]All righty, Ms. Larson.

[00:09:26]Um your lungs are clear to auscultate, both um anterior and posterior. Um we're going to go ahead and move on and listen to your five points for your heart sounds. Um and at the fifth point it's going to be your apical pulse, which is between the fourth and fifth intercostal space upon your midclavicular line, okay? And when I listen to the apical pulse, it will be for a full minute, okay? Okay.

[00:09:50]So, we're going to start out right here on the left side.

[00:09:53]And you can breathe regularly.

[00:10:04]Okay, and then do you mind if I go ahead and lift up the left breast?

[00:10:08]All right, and this will be for a full minute.

[00:11:50]>> All righty.

[00:11:51]So, as for your heart sounds, you do have strong S1 and S2. Um for your apical pulse, your pulse uh rate was 84 beats per minute. They were deep and regular. Um after I listened to your apical pulse for a full minute, I also listened to your respirations, um and that was uh 18 respiration, and they were also deep, easy, and unlabored, and you showed no signs of work of breathing, okay? Um before we progress to your abdominal area, I'm going to ask a few questions about your nutrition. Um to start, do you wear any dentures or anything like that? Mhm.

[00:12:25]>> And your teeth are okay? You can chew everything? Okay. And how many meals per day do you usually have? About two to three. Two three? And what do you usually have for those meals? Uh like veggies, rice, chicken. Okay. So, you have your protein, your veggies, and a side. And for the water that goes with it, how much water are you usually intaking in a day?

[00:12:44]About two to three cups. Okay. And have Do you drink anything with it or just water? Just the two three cups? Just about the two three cups. Okay. So, the national recommended uh daily intake should be about eight cups of water. Um you could supplement with like lemonade or tea, anything that's high in water content and low in sugar, and that would be more beneficial for like gut motility, okay? Oh, wow. Thank you. I didn't know.

[00:13:07]>> Yeah, no problem. And then we're going to change gears and switch into your bowel movements. Um when was your last bowel movement?

[00:13:13]>> Uh this morning. This morning? And about how often do you usually have a bowel movement per week? Like every other day.

[00:13:19]Okay. And do you ever have any straining or constipation or pain? Mhm. No. Okay.

[00:13:24]And then uh as for urination, when was the last time you urinated? Uh, 20 minutes ago. 20 minutes ago? And about how often in a day do you urinate? Like seven times. Okay. And do you usually make it to the bathroom? Yeah. Yes. And do you ever have any difficulty or pain?

[00:13:40]Mm, no, I don't think so. Okay. Ever any odor? No. No? Okay. So, you Would you say that the amount of water you intake equals the amount that you urinate out?

[00:13:50]Yes.

[00:13:50]>> Okay. So, that's all that we're going to ask for your nutrition. And I'm going to move on to listening to your abdominal sounds, and then I'll do some light palpations, okay? Okay. So, I'll just go ahead and help you lay down, and then I'll lift up a footrest for you, okay?

[00:14:03]Okay. Thank you.

[00:14:06]There you go.

[00:14:08]And I'm going to lift this up. The patient's chest is flat, and no signs of masses or deformities. And I'm going to start auscultating in the right lower quadrant, okay? Okay.

[00:14:19]Right here.

[00:14:27]Sorry.

[00:14:29]Okay. Bowel sounds are present in all four quadrants. And now I'm going to do a light palpation in each quadrant.

[00:14:35]Let me know if you feel any pain.

[00:14:42]Was that okay? Yeah. Now, we're going to do a deep palpation in all four quadrants as well. Okay.

[00:14:51]Okay. Any pain? No. And you did say that you used the bathroom 20 minutes before, so I'm going to go ahead and palpate your bladder as well. Okay.

[00:15:00]The patient's, uh, bladder, uh, shows no signs of distension and is soft. So, I'm going to go ahead and help you up. We're going to keep the footrest up just for a quick second, and I'm going to, um, check for your popliteal pulse behind your knee, okay?

[00:15:19]These are hard to find, but the patient's popliteal pulse plus two bilateral and equal and regular.

[00:15:26]I'm just going to check your extremities. The patient's skin color is appropriate for ethnicity.

[00:15:31]The skin is warm and warm and dry. Do you feel this, sis?

[00:15:36]Mhm. The patient's sensation in the lower extremities is adequate. Just going to check for edema.

[00:15:42]Patient shows no signs of edema. And then at the knees, the patient's skin is intact. And I'm going to come behind and just quickly check your ankles for your posterior pulse.

[00:15:56]And it is plus two bilateral, equal, and regular. And then [clears throat] now I'm going to also just check the back of your ankles. Let me know if that right ankle hurts at all. And the skin behind the ankle is intact. I'm going to go ahead and slide this in and then check your capillary refill on each of your individual toes, okay?

[00:16:19]The patient's capillary refill in the toes are less than three seconds.

[00:16:23]Um the skin is intact on the heels as well. Um now we're going to just quickly check your strength. If you can go ahead and push down on my hands. Let me know if you feel any pain and then push up.

[00:16:33]Okay, the patient's strength in the lower extremities is a five out of five.

[00:16:37]And I'm just going to go ahead and switch my gloves and then I'm going to help you up to do some quick range of motion.

[00:16:46]How are you feeling? Any dizziness, pain in that right ankle at all? No, I'm good right now. Thank you for asking.

[00:16:51]>> Okay.

[00:16:53]Now I'm just going to help you up.

[00:16:56]And if you could go ahead and just hold on to the side for stability and I'm in arms length. We're going to check the mobility in your legs, okay? Okay. So first let's flex up that left knee. Yep.

[00:17:07]And then we're going to flex up the right one. Right. And then stick the left one out to extend it and then backwards. And then for the right one, extend it forward and backwards. Okay, the patient has full range of motion in her lower extremities. And then if you could, could you just walk to the wall and back?

[00:17:27]Okay, the patient's posture is erect, the mobility is uh steady and the patient gait No, the patient's gait is steady and the patient's mobility is appropriate for age. And I'm just going to go ahead and help you back. Okay.

[00:17:39]Thank you.

[00:17:43]All righty, Miss Molly, and that concludes the entirety of our head-to-toe assessment. Um I am going to go over a few orders that I received from the doctor. So, the uh provider that was in here before me did get some vital signs. The patient's temperature was 98.8° F.

[00:18:00]Your uh blood pressure is 146/84 and your O2 saturation was 97% on room air, okay? And the doctor also prescribed 400 mg of ibuprofen every 6 hours as needed for pain. And if you have more pain with that ankle, go ahead and rest and elevate it and apply ice for 20 minutes to the ankle three times a day. Okay? And we're also hoping that you would come and visit us again in 2 weeks for a follow-up. Of course. Yeah, thank you. Do you have any questions or any concerns?

[00:18:28]>> No questions. Okay, then we're going to get right out in the hall. I'm going to give all this information to the provider and that wraps up our head-to-toe assessment, okay?

[00:18:35]>> Thank you so much.

[00:18:36]>> Miss Molly, you go ahead and have a good day, okay? You too, sweetheart.