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

Added: 2026-05-07

[00:00:00]Room scan.

[00:01:00]PP for this. Hi, my name is Kay. I'm going to be your student nurse today.

[00:01:04]Can you tell me your name and date of birth?

[00:01:05]>> Alexis 136. I'm going to check your wristband. All right. Do you have any allergies?

[00:01:13]I'm going to verify the provider's order.

[00:01:17]Today we're going to be doing a head to toe assessment. Does that sound okay?

[00:01:21]>> Mhm.

[00:01:22]>> Okay. Um [snorts] first I'll gather and clean up my equipment. Do you need anything before we begin? You need to use the bathroom glasses. You don't need hearing aids.

[00:01:31]>> Nope.

[00:01:31]>> Okay. Um do you have any questions before we begin then?

[00:01:35]>> Are you in a comfortable position?

[00:01:38]>> All right. And then I would gather and clean out my equipment.

[00:01:42]Um, have you ever had any surgeries or broken bones?

[00:01:46]>> No. Do you eat three meals a day?

[00:01:48]>> Yep.

[00:01:48]>> And do you exercise daily?

[00:01:50]>> Yep.

[00:01:51]>> Okay, perfect.

[00:01:53]Then I'll bring you over here and we'll get your vitals.

[00:02:01][snorts] Start 98.6.

[00:02:28]Okay. And then I'll do this over here.

[00:02:32][snorts] All right. 118 over 76.

[00:03:29]So that's a healthy blood pressure.

[00:03:31]Blood pressure ranges are less than 120 and less than 80 is healthy and normal.

[00:03:40]um 120 to 129 and less than 80 is elevated. 120 or 130 to 139 and 80 to 89 is stage one hypertension. Stage 2 hypertension is over 140 and over 90 or over 90. And then hypertension crisis is over 180 or over 120.

[00:04:05]Now I'm going to get your pulse.

[00:04:42]Okay. 32. So, pulse of 64. And I'm [snorts] going to count your respiration. So, just breathe normal.

[00:05:20]Okay. Eight. So that would be 16.

[00:05:21]Respirations of 16. Could you stand up for me? I'm going to check your posture.

[00:05:26]Make sure there's no lordosis, kyphosis, or scoliosis. Not seeing any of that.

[00:05:31]You have a seat. Um, and can you tell me your name again?

[00:05:35]>> Alexis.

[00:05:35]>> And then what time it is?

[00:05:37]>> 8730.

[00:05:39]>> And [snorts] where you're at?

[00:05:41]sec.

[00:05:41]>> And then Mario, you're here.

[00:05:42]>> Excuse.

[00:05:43]>> Perfect. And next, I'm going to inspect your mood and behavior. So, you're smiling at me. [laughter] So, that means you're in a good mood. You're well put together for the day. Your personal hygiene is good. And yeah, your mood is and behavior is good.

[00:06:02]Um, are you having any pain at all?

[00:06:06]>> No. Okay. If she was having pain, I would assess with old carts.

[00:06:13]Um, [snorts] now we can move on to the skin. So, I'm going to inspect the skin for rashes, lesions, scars, bruises, and color.

[00:06:28]So, inspecting nice tan color. I'm not seeing any lesions or anything like that. Um the A B CDE E pneumonic A is asymmetry, B is border, C is color, D is diameter, E is evolving or evolution. Um next I'm going to palpate your skin for any masses, tenderness, warmth. Oh wait, no. Uh texture, trigger, and temperature.

[00:07:00]It's a nice warm te uh temp, smooth texture. Do you shave your arms?

[00:07:06]>> No. Everybody asked me.

[00:07:07]>> Okay. Anyways, um next I'm going to palpate her fingers for clubbing.

[00:07:16]Um size shape.

[00:07:24]Okay. Can you take off your shoes for me, please?

[00:07:33]Okay, that's good.

[00:07:39][snorts] Next, we're going to move on to the head assessment.

[00:07:47][snorts] Okay. Um, okay. So, I'm inspecting the head for size, shape, and symmetry.

[00:08:01]And then can you tell me if you could feel this?

[00:08:04]>> Yep.

[00:08:05]>> Yep.

[00:08:08]>> Okay. Um and then can you move your head around for symmetry, range of motion?

[00:08:18]Okay. And then palpated or inspected.

[00:08:22]I'm going to palpate for any masses or tenderness. Is it tender at all?

[00:08:28]Doesn't hurt at all. All right.

[00:08:32]Um, next I can move on to the eyes. Wait, I need to grab my pen light. Can you grab it for me, please?

[00:08:43]In my um >> Yeah, [laughter] >> thanks.

[00:08:55]Okay. Um, move on to the eyes.

[00:09:04]>> Okay. I'm inspecting the conjunct no the um iris for color ses symmetry. No, color symmetry and shape.

[00:09:18]Color symmetry and shape.

[00:09:21]Okay. Okay. And then I'm inspecting the iris for color symmetry and shape.

[00:09:26]Okay. You can close your eyes.

[00:09:28]Inspecting the eyelids for lesions, edema, and lid leg.

[00:09:35]Okay. You can open back up. And then I'm going to check your conjunctiva for color and moisture. And then the scara for any lesions and then the color of them. So there's just some broken blood vessels, but that's all.

[00:09:51]Next, I'm going to check your I didn't square up. Okay. Um, next I'm going to check your pupilary reaction and accommodation. So, you can just look straight forward.

[00:10:04]Okay. The reacting to light and then follow my finger.

[00:10:09]Perfect. Next, I'll have you read this.

[00:10:12]What is the stress away? Stress away.

[00:10:15]Perfect.

[00:10:16]And then I'm going to do the six cardinal gaze positions.

[00:10:25]Perfect. All right. You read something.

[00:10:29]So, we're good there.

[00:10:39]Never palpated anything. Okay. Um, I need to palpate your eyelids for any tenderness or just or like around your eye, any masses of tenderness. Okay, that's all good there. Next, we can move on to your ears. So, I'll first inspect your ears for size, shape, symmetry, drainage, lesions, form, bodies, serumin, Size is normal to your body. Shape is also normal. I'm going to palpate.

[00:11:18]Let me know if any of this hurts or if it's tender at all.

[00:11:24]Nothing. Okay. We can come on over here then and we're going to look inside your ear.

[00:11:35]For an adult, you pull up and back. For a child, you pull down and back.

[00:11:47]Okay, I'm not seeing any redness or swelling or any foreign bodies, any drainage, just some serumin.

[00:11:59]Again, no drainage, foreign bodies, redness, or swelling. There's just room.

[00:12:03]And the coloring characteristics of the TM, it is flat. It's not bulging or retracted. And it's a pearly gray color.

[00:12:12]Now I'm going to whisper in your ear.

[00:12:16]ABC.

[00:12:18]One, two, three. Okay, perfect. Your gross hearing is intact. Now I can look at your nose.

[00:12:25][snorts] So I'll look at the outer parts of your nose for drainage, color, size, shape.

[00:12:39]Okay. And next I'm going to look inside your nose for drainage, polyps, deviations, uh color.

[00:12:52]Not seeing any of that.

[00:12:54]All right.

[00:12:59]Next, I'm going to have you smell something.

[00:13:02]Can you plug one of your nostrils?

[00:13:07]Perfect. And next I will um palpate your nose for any masses or tenderness. And then I'll palpate the sinuses for masses or tenderness as well.

[00:13:26]That's all good. And then I will move on to your mouth. So I'll inspect your lips for color, lesions, cracking, moisture.

[00:13:40]Well moisturized, no cracking lesions or color. The color is a nice pink. Can you open your mouth for me? I'm going to look at the buckle mucosa for color and moisture.

[00:13:53]And then can you put your gums down for me? Looking for color, bleeding, retractions, or lesions or edema.

[00:14:04]Um and next can you [snorts] stick your tongue out and say ah >> looking at the mobility of the uvula and then um can you just open your mouth and I'll look at the color position and size not size color position of the tongue. Can you say light tight dynamite? Light tight dynamite. Okay.

[00:14:30]And then I'm going to look at your tonsils for size and exudate and your hard and soft palette, making sure they're intact. And I would palpate it with my pointer finger. For an adult, use your pointer finger. And a child, you use your pinky.

[00:14:49]Um, light tight dynamite.

[00:15:09]Okay, next I'm going to move on to your neck. So, oh, this is where you do your range of motion. Range of motion [snorts] and symmetry.

[00:15:17]Perfect. Um, I'm going to do your lymph nodes.

[00:15:25]So we have the pre-uricular posterior uricular occipital deep cervical um tonsular submandibular submental and then the superclavicular anterior cervical posterior cervical and you range of motion is Um, next I'm going to do your um um I'm going to do your I don't know what it's called. really can't remember your I know I have to like palpate it >> your artery >> and then your corateed artery palpate it palpate it >> for tenderness and then I [snorts] can now listen to Okay. Not hearing any worries.

[00:17:01]Next we can move on to the respiratory assessment. So first I will lateral anterior ratio. So it should be one to two. So one to two. Perfect. Um and I haven't um noticed any excessive or use of the accessory muscles, her rate and rhythm.

[00:17:26]She seems to be breathing.

[00:17:29]Okay. Um could you stand up for me, please? I'm going to do your chest expansion.

[00:17:35]Chest. [snorts] Okay.

[00:17:42]Okay. No use of any accessory muscles.

[00:17:45]So, I'm going to have you say 99. I'm going to check your tactile from a tiss 99 99.

[00:17:53]>> Okay.

[00:17:55]99 99 99 Okay, perfect. [snorts] Um, you can have a seat there. I'm going to Listen to your lung sounds.

[00:18:14]10 on the front, three on the side. And [snorts] >> [snorts] >> Okay. have you stand up and I'm going to do your back side.

[00:19:37]Perfect. Okay, now you do your side.

[00:19:40][clears throat] I'm just going to run out of [laughter] breathing so quickly.

[00:19:56]Hold on.

[00:19:59]>> Sorry, I'm like in autopilot.

[00:20:08]>> All right, perfect.

[00:20:09]>> I can do this nicely.

[00:20:12]>> Um, I'll use some accessory muscles or anything. [snorts] Now we can move on to the cardio. So I'm going to inspect the precordium for wounds, deformities or scars.

[00:20:26]Not seeing any of that. I'm going to palpate for uh tenderness deformities tend um >> tetanus.

[00:20:44]>> No, not tennis. [laughter] Something like that. some T word but I don't remember what it is. Um, okay. Now I can listen to your [snorts] sounds.

[00:20:59]Um, I'm going to listen to aortic pulmonic herbs tricuspid and mitro. S1 is best heard in mitro. S2 is best heard in the aortic.

[00:21:36]Okay. Put your shirt on.

[00:22:22]Okay, 34. So that would be 68.

[00:22:28]Um, next I'm going to check for any or I'm going to palpate your skin for movement and sensation.

[00:22:43]Okay. And then while I'm down here, I'm also going to check for edema.

[00:22:48]Not seeing any edema. The edema [snorts] scale plus one is 2 mm rapid return.

[00:22:54]Plus 2 is 4 mm, 10 to 15 second return.

[00:22:58]Plus 3 is 6 mm. 1 to 2 minutes. Plus 4 is 8 mm.

[00:23:05]2 to 3 minutes.

[00:23:08]return.

[00:23:09]Okay. Um, next I'm going to check your capillary refill.

[00:23:16]Okay. I need to see your [snorts] Okay. And then I would check the other one as well and just palpate for a capillary refill. Make sure it's refilling properly and in a timely manner.

[00:23:32]Okay. Next we can move on to the abdom abdomin [laughter] pardon abdomen.

[00:23:43][laughter] Um I [clears throat] never did your pulses though either. So we'll just do that while we're here. So we have the temporal brachial radial uh the femoral popl dorsalis pedias and then the wait no pop tibialis pop dors dorsalis pe no this is the dorsalis pedias [snorts] posterior tibialis.

[00:24:21][laughter] >> This is the posterior tibialis and this is the dorsalis pedius and she would do this. Okay. Now you can bend your legs and I'm going to um inspect your abdomen for contour symmetry color leion scars dry hair distribution movement.

[00:24:39]Okay.

[00:24:42]Not seeing any of that. Next, I'm going to listen to the vowel sounds using my bell. She better put abs on her [snorts] note.

[00:25:09]They're not moving very much. I mean, I can hear them, but Not as strong as yesterday.

[00:25:17]>> I would have to eat something probably.

[00:25:19]>> What?

[00:25:19]>> Said I would probably have to eat something.

[00:25:21]>> You haven't eat anything?

[00:25:22]>> Well, I had my coffee.

[00:25:24]>> Oh, I could tell cuz your tongue is yellow. [laughter] Okay. Next, I'm going to do the um atria, aortic, renal, and iliac.

[00:25:58]Okay. And then I'm going to palpate for any tenderness, masses, urine retention, bladder distension.

[00:26:10]Not feeling any of that.

[00:26:14]Okay. Next, we can move on to your joints.

[00:26:17]Sit on the side of the bed. First, [snorts] we'll start with your I'll inspect and then Oh, that's backward. [snorts] It's [laughter] 7 in the morning.

[00:26:37]Okay.

[00:26:37]>> Okay. First, we'll start with your temporal mandibular joint. So, flexion and extension.

[00:26:46]Okay. And we'll move on to your circle spine. So, flexion, extension, lateral, and rotation.

[00:26:55]Okay. Flexion, extension, lateral, rotation.

[00:27:00]Okay. And then we'll move on to your shoulders. So, you can stand up.

[00:27:06]Flexion, extension, abduction, abduction, internal rotation, external rotation.

[00:27:13]Flexion, extension, abduction, abduction, internal Okay, then we'll move on to your elbows.

[00:27:21]Flexion, extension, supernation, pronation. Flexion, extension, supation, pronation. Okay, we'll move on to your wrists. Flexion, extension, rotation, flexion, extension, rotation. And then your fingers.

[00:27:39]So, flexion or extension, adduction, adduction, extension, adduction. Perfect. Now we'll do your hip. Flexion, extension, adduction, adduction, rotation. Other one. Flexion, extension, abduction, adduction, rotation.

[00:28:02]Flexion, extension, abduction, adduction, rotation.

[00:28:09]Perfect. Okay, you can have a seat.

[00:28:10]We're going to do your knees.

[00:28:13]So, extension, flexion, extension, flexion. Perfect. And now your ankles. Flexion or planter flexion, dorsif flexion, in eversion, inversion, inversion, eversion, down, up, in, out. [laughter] Okay. Uh those all move very well. Now we can um move on to your back. We never did your back. Um okay, flex, [laughter] extend, and rotate.

[00:28:56]That's perfect. Okay, we can move on to your muscles now. So we have your sterno mastoid muscle. So good.

[00:29:07]Good. And now your uh traps, trapezius, fleal, deltoids, deltoids. Okay. And then I can move on to your uh biceps and triceps.

[00:29:29]Okay. And then we can move on to your hips. stand and adduct. And then the other one.

[00:29:46]Okay, perfect. Now you can have a seat and we'll do your hamstrings and your um bil we'll do your bilateral hand grips first.

[00:29:57]Perfect. Okay. Um your hamstrings and your quadriceps.

[00:30:03]Good. Okay. Out and in. [snorts] Good.

[00:30:08]Nothing on your ankles. Do your back again. We'll do your back again. Okay.

[00:30:13]Down.

[00:30:16]Back. Side to side. Down.

[00:30:20]Back. Side to side. Okay. Uh you can have a seat. All of her muscles were symmetrical even on both sides. That means symmetrical sides. normal to her body. And the muscle grade scale, five is normal, four is slight weakness, three is weakness, two is poor range of motion, one severe range, severe weakness, zero is paralysis.

[00:30:48]Um, I'm going to have you walk in a straight line now, just heel to toe.

[00:30:53]Check your balance.

[00:30:56]Perfect. Now, you can walk backward as well.

[00:31:00]And then we're going to take your hands and touch your nose.

[00:31:05]Perfect. Um, you can have [snorts] a seat. Um, I'm going to inspect your remote, your memory. So, I'm going to say three words and then you're going to repeat that. Bed sock blue.

[00:31:16]>> Bed sock blue.

[00:31:17]>> And what did you have for dinner last night?

[00:31:20]>> Chick-fil-A.

[00:31:22]>> Yum. And who was your first grade teacher?

[00:31:25]>> Miss Lacy.

[00:31:26]>> Perfect. All right, that is the [snorts] end of our assessment then.

[00:31:32]Um, do you need anything while I'm here?

[00:31:35]>> All right, I'm going to ensure the safety measures that is low and locked. Side rails secured.

[00:31:46]Call within reach.

[00:31:55]Room is risk-free for any falls. Bedside table will be near and I'll clean all my equipment, document any significant findings in school according to the agency policy.