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

Added: 2026-05-25

[00:00:00]All right. Before entering the room, I would check the electronic healthcare record for any labs, new orders, or recent orders. And then I would check the doorway for any um flag or yeah, any flags or markers that would indicate like if the patient was a fall risk or something like that. Um before entering the room, I would perform hand hygiene, pretend like this has soap, and I would be doing all the other things that I would normally do when washing my hands. Um, based on these like circumstances, I don't necessarily have all the like equipment, so I would normally wash my hands like for 20 full seconds and whatever. All right, >> coming.

[00:00:49]>> Hi, I'm Abby. I'm going to be your nurse today. Do you mind if I check your wristband?

[00:00:54]>> No.

[00:00:54]>> Okay. What's your last name?

[00:00:57]>> Sh.

[00:00:58]>> Okay. And then what's your date of birth?

[00:01:00]>> 8:16 2013.

[00:01:02]>> Okay, awesome. So, what brings you in today?

[00:01:06]>> Um, my right knee hurts.

[00:01:08]>> Your right knee hurts. Okay.

[00:01:11]Can you show me where on your knee that hurts?

[00:01:13]>> Uh, like my kneecap.

[00:01:15]>> Your kneecap?

[00:01:16]>> Yeah.

[00:01:16]>> Okay. And then where does it like like does it radiate or does it just kind of stay in that spot?

[00:01:22]>> Uh, just kind of stay in that spot.

[00:01:23]>> Okay. How would you describe that pain?

[00:01:25]Would you say it's like throwing or burning or sharp?

[00:01:28]>> It's like dull. Kind of >> dull. Okay. Um and then like how would you rate it like on a scale from 1 to 10?

[00:01:36]>> Like probably five.

[00:01:37]>> A five. Yeah.

[00:01:38]>> Okay. And then when did this happen?

[00:01:41]>> Um about like two weeks ago.

[00:01:44]>> Okay. What were you doing?

[00:01:46]>> Uh well like I'm a gymnast so I was tumbling and >> I kind of just got really sore.

[00:01:51]>> Okay. Yeah. You can pull your like clothes down. Okay. Awesome. All right.

[00:01:58]So, um, we're just gonna do like a neurological assessment. So, I'm going to ask you a couple questions, and they might kind of sound a little weird, but that's just so I can assess your neuro status. Okay. All right. This is my computer.

[00:02:16]Um, where are you?

[00:02:18]>> In my room.

[00:02:19]>> Okay. What time is it?

[00:02:21]>> Uh, It's like night time.

[00:02:23]>> Okay. And then um what's your name?

[00:02:27]>> Zoe Sher.

[00:02:28]>> Okay. All right. So now I'm just going to um do a couple other thing assessments, but first I just want to ask, do you have any difficulty swallowing?

[00:02:41]>> No.

[00:02:42]>> No. Okay. And then do you have any like numbness or tingling in like your legs or your arms or fingers?

[00:02:49]>> No. Okay. All right. So, I'm going to have you sit up.

[00:02:54]Okay. Um, actually, let's have you stand up since your feet don't touch. All right. So, I'm just going to put Can you see me?

[00:03:02]>> Mhm.

[00:03:02]>> Okay. I'm just going to put my hands out like this. And then I just want you to push up against my hands.

[00:03:08]>> Ready? Okay. Good. And then do you want to squeeze my hands? Okay. Good. Does it hurt your knee to stand on it like that?

[00:03:17]>> Not really.

[00:03:17]>> Not really. Is it just kind of like rest or >> uh more just like when I'm like walking or running.

[00:03:24]>> When you're walking and running. Okay.

[00:03:26]All right. Um do you want to sit back down? And I don't think I asked you what makes it better and like the pain better.

[00:03:34]>> Um probably like icing.

[00:03:36]>> Okay. And then what makes it worse?

[00:03:38]>> Yeah, like walking or running.

[00:03:39]>> Okay. All right. Now, I'm just going to have you lay down. Okay. And I just want you to push up against my legs. Okay.

[00:03:48]And then Can you lift your legs up?

[00:03:52]Okay, that's awesome. All right. Now, um I'm just going to do a couple other assessments, but I want you to sit up for this.

[00:04:03]Okay. Can you look in my upper ear?

[00:04:06]Okay.

[00:04:11]Okay. I'm going to look at your pupil size.

[00:04:16]Okay. Awesome. Now, I'm going to do a test. It's called sharp and dull. Okay.

[00:04:22]>> So, what I'm going to do is see how I'm going to poke this pencil on it. I'm going to be like, is it sharp or is it dull? Okay. So, this one will be dull, the eraser side, and this one will be sharp. Okay. So, I'm just going to show you it on your arm. You don't have to close your eyes, but just so you know.

[00:04:37]Okay. So, this one's sharp.

[00:04:39]>> Yeah.

[00:04:39]>> This one's still.

[00:04:41]>> Okay. You ready? Close your eyes.

[00:04:44]>> Sharp.

[00:04:45]>> Okay.

[00:04:48]Okay. Then if can you see my legs down here? The legs down here. Yeah.

[00:04:54]Sharp. Okay.

[00:04:57]Sharp.

[00:05:06]Sure.

[00:05:12]Okay.

[00:05:14]Sure.

[00:05:23]Okay. Do you have like any like numbness or tingling in your legs or >> your arms? Okay.

[00:05:31]>> All right. So, I would document she did get a couple of them wrong. Um I'm kind of wondering if it might be that the pencil is too hard to distinguish, but she got most of them right, one right on each of them. So, I probably document.

[00:05:45]Um that and then all right um I think that's okay. Okay. So patient was alert and oriented times 4. Um pupil size was about 3 and 12 mm and they were direct and consensual to light. Um body position overall looked relaxed. Um proper body alignment, no odors or need for hygiene care. Um body like or facial expressions all looked relaxed as well. No ptosis or facial droop and she did not report any difficulty swallowing.

[00:06:27]Um the skin skin all looks like normal for her ethnicity. So it's not like cyanotic or pale. Um and then it's even and warm. um bilaterally as well.

[00:06:42]Um and yeah. All right. So now I'm going to do your vitals. Grab this here. Oops.

[00:06:51]Down there in the deep. All right.

[00:06:54]So this is a non-cont infrared thermometer and her temperature is 97.4.

[00:07:02]All right. Which all looks good.

[00:07:05]So now I'm just going to have you lay on down.

[00:07:10]And right now I'm going to pop the tape for the original. This cuff size is actually far too big for her arm, but we don't have another one. So obviously I would get the correct cuff size. Um it should be 40% the bladder should be 40% of the arm circumference.

[00:07:33]So because it's too big, we're going to get a low reading.

[00:07:39]Um, which is obviously going to mean that we would not interpret this as like her normal range. Okay. Um, I'm going to palpitate for Okay, the pulse oludes at around 105.

[00:08:22]So, I'm going to estimate her systolic and probably pump it up or I'm going to pump it up to probably about 12 130 or 130. Sorry. I would palpitate it.

[00:08:35]Um, yeah, 1251 130. That's right. All right.

[00:08:42]Now, I'm just going to leave this there because we have to let that set. Now, I'm going to listen to the apical pulse for one full minute. Um, my clock is right there. So, if you see me looking, that's where I'm I'm looking at that clock. Um, and then this patient would prefer to closed during the assessment.

[00:09:00]So, we obviously would listen underneath the clothes, but for this assessment, we're just going to do over the top of it. Um, and then I'm also going to listen to her respiratory rate and I'm going to like listen with the stethoscope, but I'm not actually listening with the stethoscope. I'm just like watching her breaths per minute.

[00:09:18]So, all right, we're going to start with listening to the apical pose.

[00:10:44]Okay. Um, heart rate is 65 beats per minute.

[00:10:50]Now I'm going to listen to the respiratory rate.

[00:11:46]Okay, respiratory rate is 13 breaths per minute. Um, I did listen for a full minute because I only have a clock, a digital clock here. Um, but I could just listen for 30 seconds and multiply by two. All right. Now, I'm going to take your blood pressure. Okay. Also, respiratory um was unlabored.

[00:12:07]Um can you see my >> Okay. Respiratory is all unlabored. And um the when I oscultated the apical pulse, um the pulse or the not the apical the a when I listen to the apex of the heart, um it sounded Um, no like advantageous sounds.

[00:12:35]All right.

[00:13:10]Okay, blood pressure was 80 over 64.

[00:13:14]Um, which obviously is low, but it's likely due to um the wrong cup size.

[00:13:21]All right, good job, Z.

[00:13:26]All right. Um, now we're going to do a cardiovascular and respiratory assessment. Okay. Do you want to sit up? Are you good? Or do you want to keep up?

[00:13:39]All right. So, um, I would check the if the patient was ordered an incentive sperometer, I would check um or I would teach them how to use it.

[00:13:54]And then I would also teach them deep breathing as well. And then I would check the IV for the flow and the rate.

[00:14:01]Um I would also check um there's one other thing. Um oh I would check for any TED hose or ICDs or anything like that. Um make sure that the patient was using them properly. This patient does not have Tedos or SDS, it was noted in their electronic healthcare record. Um, and there's one other thing, IV flow and rate. Um, I check that and then Yeah. And I'll think of it later. All right. Um, so now I'm going to listen to your heart sounds on your chest. Is that okay?

[00:14:45]>> Yeah.

[00:14:46]>> And do you want to lay down?

[00:14:49]>> Sure.

[00:14:49]>> Okay.

[00:14:54]All right. So, I'm going to listen to the pulmonic and the aoric which are both in mid-clavicular line second intercostal space. And then I'm going to listen to can do you want to maybe come up a little more so you can see I would listen to herbs point and then I would listen to the tricuspid or sorry yeah tricuspid and mitral as well. So yeah, perfect.

[00:16:02]Okay, no extra sounds. Now I'm going to listen to um the base and the apex and I'm going to note where the S1 and S2 is heard loud.

[00:16:36]Okay. So, S1 is heard loudest at the base. S2 is heard loudest at the apex, which is all normal.

[00:16:45]Um, now I'm going to check your capillary refill. So, I'm just going to use your hands.

[00:17:00]You hanging in there?

[00:17:02]>> Yeah.

[00:17:04]>> Okay. Do you care if I take your socks off?

[00:17:06]>> Okay. There you go.

[00:17:11]Great.

[00:17:13]Oops.

[00:17:21]Does it feel weird that I'm pinching your toes?

[00:17:24]>> Tickles.

[00:17:24]>> Tickles. Yeah.

[00:17:30]Okay.

[00:17:32]Capillary refill is less than 3 seconds.

[00:17:35]All right. Now, I'm just going to Do you mind if I roll up your like pants a little bit?

[00:17:42]Now I'm going to check verade edema.

[00:17:45]Overall like it looks all looks good here. But I'm just going to press.

[00:18:00]Okay. No edema um in the ankles and pretibial area region. All right. And then I'm going to check your pulses now. Okay. So, I'm going to start with your radial pulse.

[00:18:34]Okay.

[00:18:35]Radial pulse is three plus bilaterally.

[00:18:57]Okay. Posterior tibial is 3 plus bilateral.

[00:19:08]Yours are a little bit more.

[00:19:20]>> Okay. Then dorsalis pettis is 3 plus bilaterally. Do you want me to put your sock on?

[00:19:26]>> Sure. Do you want to? Yeah, you got it.

[00:19:29]Okay.

[00:19:31]All right. Um, now we're going to do finish up our respiratory.

[00:19:37]Um, yeah, I would check I think what the one thing that I forgot was the FiO2. I would check that one as well to make sure that it's on and working. Um, yeah, I know there's one more. Think of it.

[00:19:51]Okay. Um, do you want to sit and turn this way so you're facing the window?

[00:19:56]Yeah. All right.

[00:20:05]All right. Take a deep breath in.

[00:20:19]Nice deep breaths.

[00:21:03]Okay.

[00:21:04]All right. Now, I'm going to do the front of you again.

[00:21:13]All right.

[00:21:16]Do you want to take a deep breath in?

[00:21:45]Okay. I'm pretty sure there's no crackles or wheases, but I was obviously doing it over clothes, so there was a lot of background noise. Um, but her, um, breath sounds all sounded normal. It seemed like there wasn't. Um, yeah. And then I just have a couple questions for you. So, do you have like a cold or have you had one recently?

[00:22:06]>> No.

[00:22:07]>> No. Okay. Um, if you did have a cold, one thing that's really important to tell your doctor is if you're coughing up any like mucus. Um, and then you would want to know like the color and the amount.

[00:22:19]>> So like if it was like dark yellow, you'd want to know that it was like green, you want to know that.

[00:22:26]>> And then you'd want to also know the amount. So like if it was like a lot, like if you were coughing up like maybe like a whole like cup of it. Like a lot a lot.

[00:22:41]>> Or maybe you just coughed up a little bit and you would want to know that how much you're coughing.

[00:22:45]>> Yeah.

[00:22:45]>> Does that make sense?

[00:22:46]>> Yeah.

[00:22:46]>> Yeah. Okay.

[00:22:48]All right. Um now we're good. So we're going to move on to the abdomen. So I'm just going to palpate your abdomen and you're just going to tell me if there's any pain and but first I'm going to listen. Okay.

[00:23:04]>> All right.

[00:23:07]So, I'm going to start in the right lower quadrant.

[00:23:10]Um, her abdomen looks flat. Um, it's not rounded, descended, or protuberate.

[00:23:49]Okay. So, I heard about six bowel or I heard six vowel sounds per minute. Um, that's normal. You should hear about or I heard about I heard six in one minute.

[00:23:59]Um, you should hear about between 5 to 30. So, that's awesome. All right. Now, I'm going to palpate for any pain. So, you just tell me if you feel any pain.

[00:24:09]Okay.

[00:24:17]Yeah, just relax your tongue and stomach a little. Okay, there you go.

[00:24:26]All right. Um her stomach is a little bit guarded but after a while I it seemed to be or the guarding went away and um yeah there's no masses or any lumps stomach. Um and we couldn't really palpate for any organs as well. So was good. All right.

[00:24:49]Now we're going to move on.

[00:24:54]So I just have a couple questions. One was the last time you had a bowel movement?

[00:24:59]>> Um, probably like one or two days ago.

[00:25:01]>> Okay. One or two days ago. Um, and what was your bowel movement like? Was it like brown?

[00:25:09]>> Was it okay?

[00:25:11]>> What can you tell me like the color >> exactly? It was brown. Was it like a light brown?

[00:25:17]>> Okay. Dark brown. Okay.

[00:25:19]>> Um, and then did you notice anything else that seemed weird about it?

[00:25:24]>> No.

[00:25:25]>> No. Okay. So if it's kind of lumpy or if it's kind of like like if you have diarrhea or something like that, you would want to note that. Um that would be something important, especially if you have it a lot, you know. So um and then when was the last time you urinated?

[00:25:41]>> Um probably like an hour ago.

[00:25:43]>> Okay. Yeah, an hour and ago. Okay. And what would was you would want to know like the color?

[00:25:50]>> It was like light yellow.

[00:25:51]>> Light yellow. Okay. And amount would be good like if you are urinating a little bit. That's something that could be something like an infection.

[00:26:00]>> So, we want to know if it was like normal or not.

[00:26:03]>> It was normal for you. So, how >> So, um what else? And then color, the amount.

[00:26:13]Um yeah. And then if this patient had a fully catheter, we would inspect the fully catheter. Um but she doesn't. Um And then I forgot we're then we're going to do the skin assessment. So we would do the brain and scale if the skin assessment wasn't right. And then the more scal if um or the yeah the mor scal if this patient had like fall risks or something but this patient can walk and stuff when she did her range of motion test. So I don't think she's at risk for falling. Um and she was able to walk into the um visit to the her appointment on her own. So, all right. So, now I'm just going to test your skin.

[00:26:59]All right.

[00:27:05]And then I would do this under her clothes, but All right. Her skin feels even. There's no lesions. Um, if she had an IV, I would inspect the IV site, but no IV, so we're good.

[00:27:20]And then I would do the braiding scale if I found any like um skin breakdown.

[00:27:25]Um I would also turn the patient if she had any like other um major like skin issues. So like if she had like a pressure ulcer like I would turn her.

[00:27:36]Um and I think that's all. Um before I leave the room um I would make sure that all the guard rails are up. that the bed is low and locked and the collite is within reach. Um, obviously this is not a setting in this hospital. Um, and then yeah, I think that's all before I leave the room. I would also perform hand hygiene again. Um, and yeah. All right. Thank you so much for coming to the appointment. If you have any other questions, everything all looks good and within normal limits, um the doctor will come in for to check your knee. Okay. Make sure it's all good. But >> all right. Thank you so much.

[00:28:27]>> See you later. All right. Bye.

[00:28:29]>> And then before I leave, I would perform hand hygiene um right after. Um but I don't really have like a hand sanitizer.

[00:28:37]So yeah. All right.