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

追加: 2026-05-07

[00:00:03]I'll come in.

[00:00:06]>> Hi, how are you today?

[00:00:07]>> Good. How are you?

[00:00:08]>> My name's Greta. I'm going to be your student nurse. I'm just performing some hand hygiene. Going to provide some privacy. Can you tell me your first and last name?

[00:00:16]>> Audrey Stevens.

[00:00:17]>> And what's your date of birth?

[00:00:19]>> 1222 2000. I'm just going to double check that. Sounds good. Um, can you tell me where we are today?

[00:00:25]>> 233 Gas.

[00:00:27]>> Okay. And what day of the week is it?

[00:00:29]>> It is Wednesday.

[00:00:31]>> All right. So, that shows me that you're oriented times three, which is perfect.

[00:00:35]Can you do you have any pain or discomfort?

[00:00:38]>> I have a sore throat.

[00:00:39]>> You have a sore throat. Can you show me where?

[00:00:42]>> Right here.

[00:00:43]>> Right here. Oh, yeah. Your seem pretty enlarged. When did that start?

[00:00:47]>> Two days ago.

[00:00:48]>> Two days ago. Is there anything that helps and relieves the pain?

[00:00:53]>> Um, cold medicine.

[00:00:55]>> Anything that makes it worse? No.

[00:00:57]>> Okay. And out of a scale of 1 to 10, like 10 being the worst and one being like nothing, what's the >> six?

[00:01:05]>> Six. Okay. So, after this assessment, I'll get someone to come in and take a look at it. So, we're going to do a headtotoe assessment. I'm going to start with the lungs and just go throughout the body. If you have any questions, comments, concerns, just let me know.

[00:01:19]And if you're feeling any more pain or discomfort, just let me know and we'll go from there. So, I'm going to start with listening your lungs. Just by talking to you now, I can tell that you're not using any accessory muscles and they seem pretty easy, but I'm just going to listen to your bronchial vicular sense. Good. So, if you wouldn't mind just putting your feet flat on the floor.

[00:01:40]Awesome. And every time I switch my set, go to somewhere else. Just take a big big inhale and exhale. All right.

[00:01:48]>> Yes.

[00:02:13]And I'm going to do the same thing on your back.

[00:02:20]Inhale and exhale.

[00:02:36]And then I'm going to do the same thing on your sides and then other arm.

[00:02:55]Okay. So, your breath sounds are very normal. I don't hear any wheezing or crackles or anything like that. We're going to now listen to your heart.

[00:03:06]Any questions so far?

[00:03:07]>> No questions.

[00:03:08]>> Okay. Awesome.

[00:03:11]So, we're going to start with the aortic area, which is the right sternal border, second intercostal space.

[00:03:19]Then the pulmonic, which is left sternal border, second intercostal space.

[00:03:25]Then herbs point which is third intercostal space left sternal border.

[00:03:33]Tricuspid fourth intercostal space left sternal border and mitral which is the fifth intercostal space left midclavicular. I'm going to palpate it.

[00:03:47]Okay. So it's right in line with the left left mid cubvicular line meaning that it's not shifted or enlarged or anything like that. Just going to go back and double check that you don't have any extra sounds or murmurs.

[00:04:10]Okay, sounds great. So, now I'm just going to take a look at your upper extremities.

[00:04:16]I see warmth, pink, noations, lesions, rashes, lumps, or anything like that. And we're going to do the capillary refill.

[00:04:30]And on this hand, too.

[00:04:33]So, that's under 3 seconds, which is great. One more check for pulses.

[00:04:42]Both are two plus bilaterally, which is great. And I'm going to ask you to lay down.

[00:04:50]I'm going to take a look at your abdomen. The contour looks flat, symmetrical, and warm. Yes, it's warm. And And now I'm going to listen to it with your bowel sounds.

[00:05:23]So, I can hear gurgles and clicks in all four quadrants, which is completely normal. I'm just going to go back with my bell and listen to your vascular sounds to make sure there's no bruise.

[00:05:39]Okay, sounds good. And then I'm going to lightly palpate. Just let me know if you have any tenderness, pain, discomfort, anything like that.

[00:05:48]>> Okay.

[00:05:51]Does that feel okay?

[00:05:52]>> Yes.

[00:05:53]>> Any pain?

[00:05:54]>> No.

[00:05:56]>> Okay.

[00:05:57]>> So, you can either lay down or sit up if you want, but I'm going to check your lower extremities.

[00:06:02]Okay.

[00:06:05]No edema swelling. They look nice and pink, dry, and healthy. I'm going to check your PETA.

[00:06:18]Two plus bilaterally again. So, that's the end of the assessment. Everything's pretty normal. I'm going to come back with somebody else to take a look at your throat because that seems to be bothering you today. Um, here is your clicker. If you have any questions, comments, concerns, just take a click on the button and we'll come right back.

[00:06:39]And then yeah, just relax until the doctor comes and put you in your most comfortable position.

[00:06:47]And um yeah, that's about it. Have a good day.

[00:06:50]>> Thanks, Nurse Grad.

[00:06:51]>> You're welcome.