HEAD TO TOE ASSESSMENT

[00:00:00]Okay, this is going to be our nursing assessment video. This is my patient Kenzie.

[00:00:06]Um we already pre-alcohol swabbed our stethoscope and we're going to use our diaphragm as the um reflex hammer because we don't have that today.

[00:00:19]Hi, my name's Gracie. I'm going to be your student nurse today. How are you?

[00:00:23]I'm good. How are you? Good. Um can I get your name and your date of birth?

[00:00:27]>> McKenzie Lynn, 04/15/1743.

[00:00:32]>> Perfect. Okay. And then um could I Do you know where we are right now?

[00:00:36]>> Gracie's house.

[00:00:37]>> And about what time is it?

[00:00:39]>> 4:30 p.m.

[00:00:40]>> Okay, perfect. The patient is sitting upright. Um she is well-kempt in a safe environment and responsive to all my questions.

[00:00:50]Um she is oriented to times three to place, time, and person.

[00:00:58]And um now your doctor ordered a head-to-toe assessment. Um we're going to start by touching your head. Is that okay with you?

[00:01:05]>> Yes.

[00:01:05]>> Okay, perfect. Let me know. Do you feel any pain or tenderness?

[00:01:09]>> No.

[00:01:10]>> Okay, and I'm going to look at your hair.

[00:01:13]Perfect. So, the head is normocephalic.

[00:01:16]Um face is symmetrical. The neck is proportionate and proportionate to the head and hair growth is normal and there there's no lice or um dandruff noted.

[00:01:30]Um okay. Now, we are Now, I'm going to feel here at your trachea. So, the trachea is midline and I'm going to feel your arteries next. So, your temporal arteries.

[00:01:46]And the carotid.

[00:01:50]And this side.

[00:01:54]Okay, the temporal and carotid arteries are palpable bilaterally. Now, I'm just going to listen for any um carotid bruits.

[00:02:04]So, if you just want to take a deep breath in and hold it.

[00:02:12]And out.

[00:02:13]And breathe in and hold it.

[00:02:21]Okay, breathe out.

[00:02:22]No carotid bruits auscultated bilaterally. Okay. I'm going to feel your lymph nodes now.

[00:02:30]Any pain or tenderness?

[00:02:32]>> No.

[00:02:33]>> Okay. Um lymph nodes are non-palpable and non-tender bilaterally. Now, we're going to look at your eyes.

[00:02:41]Um if you just want to go like this, so the conjunctiva's pink, sclera's white, no jaundice or drainage is noted.

[00:02:50]Okay, if you just want to follow my pen with your eyes only, not your head.

[00:03:02]Okay, perfect. And now I'm just going to shine the light to make sure your pupils are good. Okay, now if you want to go like this for me.

[00:03:16]Good.

[00:03:17]Okay. Um and your pupil size is about 4 mm. So, EOMs intact, no uh nystagmus noted. The pupils are equal, round, reacted to light, um direct and consensual.

[00:03:36]Uh and accommodation convergence noted.

[00:03:40]Pupil size is noted as about 4 mm bilaterally. Okay, and I'm just going to look at your ears. So, is there any pain or tenderness here?

[00:03:49]>> No.

[00:03:49]>> What How this?

[00:03:50]>> No.

[00:03:51]>> And >> No.

[00:03:53]>> Perfect. Okay. So, the external ears are intact and symmetrical. The color's consistent with the exposed skin. The pinna and tragus are mobile and non-tender bilaterally. Now, we're going to look at your nose. The nose is symmetrical. If you just want to go like this and breathe in. And now on the other side. Good. So, the nose is midline and symmetrical and nares are patent bilaterally.

[00:04:18]Now, we're going to look in your mouth.

[00:04:19]If you just want to open and say "Ah."

[00:04:22]>> Ah.

[00:04:23]>> Good. Okay. The tongue is pink, moist, and without lesions. The buccal mucosa is pink, moist, and without lesions, as well. And um the dentition is intact and the uvula rises with phonation.

[00:04:38]Okay.

[00:04:39]Um now, the client's sitting upright. If you just want to take a deep breath in and out.

[00:04:45]Um respirations are regular, even, and non-labored. The rise and fall or The rise and fall of the posterior chest is symmetrical and the color is consistent with exposed skin. So, now we're going to listen to the posterior and anterior chest.

[00:05:05]The breath sounds. So, every time I move my stethoscope, just breathe in and breathe out.

[00:05:10]Okay.

[00:05:40]Okay. Now, we're going to listen on the anterior chest.

[00:06:12]>> Okay.

[00:06:14]Bilateral breath sounds are clear to auscultation on the posterior anterior chest and all lobes. Good respiratory effort, no adventitious sounds are noted bilaterally.

[00:06:27]Now, we're going to listen to your heart sounds. So, we're going to do aortic, pulmonic, Erb's point, tricuspid, and mitral. So, first we're going to listen with the um diaphragm, and then we'll listen with the bell.

[00:06:46]Okay.

[00:06:47]Just breathe normally for me.

[00:07:18]Okay, now we're going to listen with the bell.

[00:07:49]>> Okay.

[00:07:50]Um S1 and S2 heart sounds auscultated with normal rate and rhythm. No S3 or S4 sounds or murmurs were auscultated with the bell.

[00:08:03]And again, this would be aortic, pulmonic, Erb's point, and then tricuspid, and mitral.

[00:08:12]Um now we're going to look at the abdomen, and normally your patient would be laying supine, but we don't have a bed right now, so we're just going to improvise.

[00:08:20]So, here we're going to take two looks from two different angles.

[00:08:26]Okay?

[00:08:27]The abdomen is flat, no bulges, lesions, scars. Um now I'm going to listen.

[00:08:34]Uh all Normally, we would auscultate for more than what we're going to do for this video. It's 1 to 2 minutes, but for the sake of this, we're just going to minimize it and listen for a second.

[00:09:09]Okay. All sounds were auscultated in each of the four quadrants. Um now I'm going to palpate the abdomen. Let me know if you feel any pain or tenderness.

[00:09:21]And we're going to palpate in three areas.

[00:09:25]Any pain or tenderness?

[00:09:26]>> No.

[00:09:27]>> Okay.

[00:09:28]There.

[00:09:31]Okay.

[00:09:31]>> No.

[00:09:32]>> Perfect. Uh no pain or tenderness in all any of the four quadrants upon palpation.

[00:09:40]Okay, now I am going to feel your wrists and your ankles.

[00:09:46]Okay, no lower or upper body edema is noted bilaterally. Now, I'm just going to feel your skin.

[00:09:55]Um skin is warm and intact. Color is consistent throughout and no lesions or tattoos noted.

[00:10:05]Now, if you want to go like this and I'm just going to here. Okay, the skin turgor is appropriate. No tenting noted. Now, we're going to check your capillary refill. So, here and here. Capillary refill is less than 2 seconds bilaterally. Now, I'm just going to feel um your joints. Let me know if you have any pain or tenderness.

[00:10:32]Any pain or tenderness?

[00:10:34]>> No.

[00:10:35]>> Okay. What about here?

[00:10:37]>> No.

[00:10:37]>> Here?

[00:10:39]Okay. So, no swelling, tenderness, redness noted in the shoulders and any pain or tenderness in the elbows?

[00:10:49]>> No.

[00:10:49]>> Okay.

[00:10:50]Um in the elbows, wrists, hips, knees, or ankles.

[00:10:55]Um uh client denies pain with palpation.

[00:11:00]So, now if you just want to stand up, we're going to test your range of motion. So, just copy what I do. Just here and around and down and behind your back and out in front of you.

[00:11:14]Okay. And okay, so the client has equal range of motion in all joints bilaterally. Now, we're going to test your strength. So, push against my hand and against against up and now your hands. Push up and push down. And then um for your leg, you can hold on to the table.

[00:11:39]And push up against me and down. Okay, and up.

[00:11:44]And down. Okay, now while you're standing, we're going to look at your walking. So, if you just want to walk towards me and then walk back heel to toe.

[00:11:56]Good. Okay, you can come back and have a seat.

[00:12:01]So, um strength in the head, shoulders, wrists, ankles, knees, and hips were all good bilaterally.

[00:12:14]Um the gait, she can walk back and forth without any um stumbling and she can walk heel to toe without any issues.

[00:12:22]She's stable.

[00:12:23]Um okay, now we're going to test your reflexes.

[00:12:29]Again, we're using the diaphragm because we don't have a reflex hammer.

[00:12:35]So, here and here.

[00:12:38]And then here.

[00:12:40]Good. Okay, uh the um patellar reflex is um seen bilaterally on this or on her.

[00:12:52]Um okay, now we're going to look at your um pulses.

[00:12:58]So, here and here.

[00:13:05]Okay. So, the pulses are strong and equal, approximately two plus. And now, if I could just have you close your eyes and um I'm going to feel on your hands and tell me what finger I'm touching.

[00:13:19]>> Right middle finger.

[00:13:21]>> Good. And here.

[00:13:22]>> Left index finger.

[00:13:24]>> And here.

[00:13:25]>> Right big toe.

[00:13:27]>> And here, left pinky toe.

[00:13:29]>> Okay, the client is able to feel my touch bilaterally on hands and feet um without any issues and um that completes the head-to-toe assessment today. Do you have any questions for me?

[00:13:45]Okay, here's your call light and if you need anything, then feel free to just press that and I'll come right over.

[00:13:52]>> Thank you, nurse.