Head to Toe Assessment on a Female Patient | 85 | Unintentional ASMR

Hinzugefügt: 2026-05-22

[00:00:00]Hi, my name is Sydney. I'm going to be your student nurse today. We're going to be performing a health assessment.

[00:00:05]First, I'm going to perform hand hygiene.

[00:00:08]Next, I can tell by looking at your general appearance that I you show no signs of deformities and that you're well-groomed.

[00:00:15]I can tell that you show no signs of physiological distress like labored breathing, bleeding, seizure activity, vomiting, diaphoresis, or expressions of pain. Now to check your level of consciousness, can you I'm going to ask you three questions. What is your name?

[00:00:29]Where are we? And what time is it?

[00:00:31]Avery, Fayetteville, Arkansas, and April.

[00:00:35]Awesome. I can tell you're oriented times three. Your speech is clear, articulate, and you're cooperative.

[00:00:41]So now, moving on to the head and scalp, I can tell that your scalp is an even contour, it's symmetrical, and you have even hair distribution. I see no presence of trauma. Do you feel any tenderness? No.

[00:00:56]Patient denies tenderness of the scalp, so now I'm going to check your TMJ joint. Open your mouth.

[00:01:02]Close your mouth.

[00:01:03]I felt no crepitus of the TMJ TM TMJ joint. Now I'm going to check your frontal and maxillary sinuses. Do you feel any tenderness? No. No. Okay, patient denies tenderness of the frontal maxillary sinuses. Now I'm going to have you smile, frown, and then puff your cheeks.

[00:01:22]Your face symmetry tells me that your cranial nerve seven is intact.

[00:01:26]So now I'm going to move on to the respiratory system. No, I'm not. Sorry.

[00:01:33]Now I'm going to have you open your mouth.

[00:01:38]I'm sorry.

[00:01:39]Sorry.

[00:01:42]I can tell that your oral mucosa is pink and moist, and your tonsils are one plus and present. Can I have you say "Ah"?

[00:01:50]Ah.

[00:01:51]And then um your uvula rises midline, which tells me that your cranial nerves nine and 10 are intact. Now, I'm going to have you stick out your tongue.

[00:02:00]Great. That tells me your tongue your tongue protrudes midline, which tells me your cranial nerve 12 is intact.

[00:02:06]So, now I'm going to check your eyes.

[00:02:08]I'm going to pull down on your conjunctiva.

[00:02:12]I can tell that your conjunctiva is pink and your sclera is white and clear.

[00:02:17]So, now I'm going to check for the six cardinal fields of gaze. Follow my finger without moving your head.

[00:02:33]One more.

[00:02:35]Great. Her eyes track fine, and I see no nystagmus present.

[00:02:39]So, now I'm going to check for PERRLA, which means I'm going to just shine a light in your eye. I just want you to look at something on the wall.

[00:02:50]Sorry.

[00:02:51]Um your eye your pupils are round um symmetrical and react to light directionally and consensually. So, I'm going to check for accommodation. Just look at something on the wall, and then look at my finger.

[00:03:05]Great. So, that tells me that your eyes accommodate to near and far.

[00:03:09]So, now I'm going to move on to the respiratory system.

[00:03:12]Um first, just by inspecting your chest, I can tell that you have um a symmetrical chest, and I see no signs of accessory muscle use.

[00:03:22]So, now I'm going to listen to your breath sounds. I'm going to listen to six positions in the front, and then eight positions in the back.

[00:03:30]Just take a breath every time you feel my stethoscope touch your chest.

[00:03:58]>> Back.

[00:04:13]Can I have you lean forward a little bit?

[00:04:22]I heard clear breath sounds and no adventitious breath sounds. So, now I'm going to move on to the cardiovascular system. I'm going to have you lean back in your chair just a little bit.

[00:04:32]Um just by inspection, I can tell that your skin is even and tan and you have even hair distribution.

[00:04:38]Um so, now I'm going to palpate your peripheral pulses.

[00:04:50]First, we have brachial, radial, femoral, popliteal, posterior tibial, and dorsalis pedis.

[00:05:04]Your peripheral pulses are a two plus out of four and even bilaterally. So, now I'm going to palpate your inguinal nodes. Do you feel any tenderness? No.

[00:05:13]No, patient denies tenderness. I do not feel enlargement of the inguinal nodes.

[00:05:17]Now, I'm going to feel for skin temperature using the back of my hand.

[00:05:22]Your skin is warm to the touch and moist. Um so, now I'm going to check skin turgor under your clavicle.

[00:05:30]I see no tenting, which is a great sign.

[00:05:33]Um and now I'm going to check for lower extremity edema using my thumbs, two points on the shin, on the tops of the feet, and on the backs of the heels.

[00:05:43]That is a zero out of four um on the edema scale.

[00:05:49]So, now I'm going to check capillary refill on your fingers and toes.

[00:06:08]Capillary refill is less than 2 seconds um bilaterally, which is a good finding.

[00:06:13]So, now I'm going to listen to your heart sounds.

[00:06:17]I'm also going to name them as I listen to them.

[00:06:24]First, we have aortic, which is the first intercostal space at the um second intercostal space on the right side. Then, we have the pulmonic, which is the second intercostal space on the right side.

[00:06:37]Then, we have Erb's point, which is the third intercostal space at the sternal border.

[00:06:42]Then, we have tricuspid, which is left of the sternal border, and mitral, which is the fifth intercostal space at the midclavicular line.

[00:06:51]I heard no quick gallops or murmurs um in your heart sounds so or any bruises.

[00:06:57]Um so, now I'm going to move on to the um abdomen.

[00:07:03]So, I'm going to have you lay down.

[00:07:05]Head on the pillow.

[00:07:08]Feet up. Yes.

[00:07:10]I can tell by looking at your abdomen that it is in even contour. You have even hair distribution um and everything looks symmetrical.

[00:07:18]So, now I'm going to um listen with my stethoscope in all four quadrants.

[00:07:44]I heard hyperactive bowel sounds in all four quadrants.

[00:07:47]So now I'm going to percuss and then palpate in all four quadrants.

[00:07:57]And then I'm going to name the organs in each quadrant. So in your right lower quadrant you have your ascending colon and your appendix.

[00:08:04]Your right upper quadrant you have your liver and your gallbladder.

[00:08:08]Your right your left upper quadrant you have your spleen, stomach and pancreas. And in the left lower quadrant you have your sigmoid colon.

[00:08:18]Okay, so I'm going to have you sit up now.

[00:08:26]And moving on to the muscular system, I can tell just by looking at your legs and your extremities and your neck that you have no swelling or deformities.

[00:08:37]So now I'm going to have you squeeze my fingers with your hands.

[00:08:41]Those were strong and a five plus out of five plus against resistance. So now I'm going to have you do this and pull and push and do it on your feet. Push and pull.

[00:08:56]Both extremities were a five plus out of five on the muscle scale against resistance. So now I'm going to have you stand up and I'm going to point out the pressure points on the body for skin breakdown possible for skin breakdown.

[00:09:12]First you have occiput on the back of the head, shoulders, scapulas, sacrum, elbows, your ischial tuberosities, your trochanters, your lateral and medial knees, your lateral and medial malleoluses and then the backs of your heels. That concludes our assessment. Thank you. Thank you.