- 1. Verify unit/facility policy
- 2. Assemble equipment
- 3. Introduce self to client
- 4. State purpose of the nurse/client interaction
- 5. Identify the patient with 3 determining factors: name, date of birth, medical record #
- 6. Provide for privacy
- 7. Wash hands
- 8. Drape/gown client appropriately
Hair- step 1:
1. Inspect hair on scalp for color, distribution
Result: Even distribution; (state color)
2. Separate hair with blunt end of Q-tip to visualize the scalp. Inspect for dandruff, lesions or pest inhabitants.
Results: No dandruff, lesions or pest inhabitants.
Hair- step 3.
3. Palpate hair and scalp for lesions and hair texture.
Results: hair texture smooth; no palpable lesions.
Skin and nails- step 1.
1. Inspect skin head to toe, APL for color, lesions, visible edema, erythema, variscosity, hair distribution.
Results: Skin is pale pink/flesh colored with even pigmentation; no visible lesions, edema, erythema, varicosity; body hair distribution even.
Skin and Nails-step2
2. inspect all fingernails and toenails for color, shape, contour bilaterally.
Result: Fingernails smooth rounded, cuticles intact, nail beds pink.
Skin and Nail- step 3.
3. Inspect at least one fingernail on each hand for clubbing (index nails together, should see light through a diamond shape)
Result: No clubbing bilaterally
Skin and nails- step 4.
4. Palpate at least one fingernail on each hand for capillary refill
Result: Capillary refill < 3 second bilaterally
Skin and Nail-step 5.
- 5. Check skin turgor/mobility on neck upper chest in one location.
- (Pinch skin to see if it 'tents')
Result: Turgor: instant recoil, no tenting
Skin and Nail-step 6.
6. Palpate skin with back of the hand for temperature: Include face, arms, and legs bilaterally.
Results: Temperature warm bilaterally
Skin and nails- step 7.
7. Palpate skin with palm of the hand for moisture and texture: Include arms legs, bilaterally
Result: Skin dry, texture smooth bilaterally
Skin and nails-step 8.
- 8. Palpate pretibial edema bilaterally, depress for 5 seconds
- (6 inches above ankle)
Result: No pretibial edema bilaterally
Skin and nails-step 9.
9. Palpate feet bilaterally for temperature, moisture, texture. Separate toes and note skin condition.
Results: Temperature warm, dry bilaterally
Skin and nails-step 10.
10. Palpate at least one toenail on each foot for capillary refill
Result: Capillary refill < 3 seconds bilaterally
1. Instruct client to close eyes for Trigeminal nerve sensory test.
2. With a cotton wisp, test sensory on 3 areas of face, forehead, cheeks, chin bilaterally. Ask client if the sensation is felt equal on each side. (CN5)
Result: Trigeminal light touch able to be felt equally bilaterally
3. Instruct client to close eyes for light touch test.
Neuro- step 4.
4. Test light touch with cotton ball randomly on upper arm, forearms, hand, thigh, leg, foot bilaterally. Ask client "is this the same as this" on each side. *3 touches in each area.
Result: Light touch present and felt equally bilaterally on anterior upper arms, forearms, hand, thighs, lower legs, and top of feet.
5. Instruct client to close eyes for sharp/dull test
*Break tongue depressor for this test
6. Test sharp and dull beginning peripherally on the hands and feet, including 3 places on each bilaterally. Wait 2 seconds between applications of stimulus. Ask client to say "sharp" or "dull" in response to the sensation felt.
Result: Pain present and equal in C-6,7,8, on dorsal side of hands bilaterally, and S1-2, and L4-5 on dorsal side of feet bilaterally.
7. Observe rapid alternating movements bilaterally, hand to thigh (Motor-Cerebellar Function: coordination).
Results: Coordinated skilled smooth rhythmic turning.
8. Hand grips for strength bilaterally. Offer patient 2 fingers, both hands at the same time.
Results: Hand grips equal bilaterally
9. Deep tendon reflexes: biceps, triceps, brachioradialis bilaterally (with pointed side of reflex hammer), and quadriceps, Achilles, and plantar bilaterally (flat side of reflex hammer).
Results:Deep tendon reflexes (DTRs) +2 bilaterally
10. Ask Client to stand up and walk across the room with normal stride, turn, walk back toward examiner with heel to toe (tandem) gait. (Motor-Cerebellar function: balance)
Results: Gait steady, smooth with appropriate arm swing; able to tandem walk
11.Romber test (Motor- Cerebellar function: balance)- have patient stand feet together, arms at side, and close eyes for 20 seconds (stand close by)
Result: Romberg negative.
Head and Face-step 1.
1. Inspect face for expression and symmetry
Result: face symmetrical
Head and face-step 2.
2. Instruct client to smile, frown and close eyes tightly, and resist your attempts to open them bilaterally. Observe for equal strength and symmetry (CN VII-facial)
Results: Face symmetrical with smile, frown; eye muscle strength 5/5 bilaterally.
Head and face-step 3.
3. Instruct client to lift eyebrows, show teeth, puff out cheeks. With cheeks puffed press cheeks in and note air escape equally on both sides. Observe for symmetry of movement (CN VII-facial)
Result: Face symmetrical with lifting eyebrows, frown, smile, puff cheeks, show teeth; air escapes equally bilaterally.
Head and face-step 4.
4. palpate skull for size, shape, symmetry
Result: Head normocephalic
Head and face-step 5
5. Palpate temporal artery bilaterally
Results: Temporal artery pulses present and equal bilaterally
Head and face-step 6.
6. Instruct client to clench teeth. Palpate temporal and masseter muscles (TMJ). Attempt to separate the jaws by pushing down on the chin. (CN V-Trigeminal)
Result: TMJ muscle strength 5/5, equal bilaterally.
Head and face-step 7.
7. Palpate frontal & maxillary sinuses for pain and edema, bilaterally.
Result: Frontal & maxillary sinuses non-tender, no edema bilaterally.
1. Inspect external eye structures-eyebrows, eyelids, eyelashes bilaterally
Results: even distribution of eyebrows, eyelashes; no ptosis bilaterally.
2. inspect conjunctiva, sclera, cornea, iris bilaterally
Result: Conjunctiva pink, sclera white, cornea smooth, iris (state color) bilaterally
3. Inspect extraocular muscle (EOM) function: corneal light reflex bilaterally using pen light.
Result: Corneal light reflex symmetrical
4. PERRLA (CN III, IV, V-oculomotor, trochlear, trigeminal)
Results: Pupils Equal, Round, React to Light, Accommodation.
- 5. inspect 6 cardinal positions of gaze (CN III, IV, V-Oculomotor, trochlear, and trigeminal)
- *Hold pen in front of eyes and ask pt to follow pen, just with eyes, in the positions of the clock)
Results: Pupils move parallel in 6 cardinal fields of gaze
6. Inspect extraocular muscle (EOM) function: cover/uncover test bilaterally.
Results: cover/uncover reveals fixed, steady gaze.
7. Fundoscopic exam-red reflex bilaterally.
Results: Red reflex present bilaterally.
1. inspect external ear for size, shape, and skin condition bilaterally
Results: External ear equal size, shape, height bilaterally.
2. Palpate pinna, tragus, and mastoid process for tenderness bilaterally
Results: Pinna, tragus, and mastoid process non-tender bilaterally
3. Otoscopic exam-inspect external, internal ear canal and tympanic membrane bilaterally
Results: External ear canal skin intact; tympanic membrane pearly grey, cone of light bright bilaterally.
4. Test hearing: whisper test bilaterally (CN VIII-Auditory)
Results: Able to repeat whispered words bilaterally.
1. Inspect external nose for symmetry
Results: Nose symmetrical, no deformities or lesions
2. Inspect nasal mucosa, septum, turbinates bilaterally with a pen light.
Results: mucosa & turbinates pink, moist, no exudates bilaterally; no septal deviation or perforations bilaterally.
Nose- step 3.
3. Test patency of each nostril; occlude one nostril at a time.
Results: Nares patent bilaterally
Mouth and throat-step 1.
1. Inspect mouth using penlight and tongue blade. Note: buccal mucosa, teeth, gums, tongue, floor of mouth, grade tonsils if present.
Results: Buccal mucosa, floor of mouth, and gums pink, moist, no masses or lesions, teeth present and in good repair, tongue smooth; tonsils (grade)
Mouth and throat-step 2.
2. Observe tongue position upon protrusion (CN XII-Hypoglossal)
Results: Tongue protrudes midline
Mouth and throat-step 3.
3. Note mobility of uvula with phonation (CN IX, X-Glossopharyngeal and Vagus)
Results: Uvula rises with phonation
Mouth and throat 4.
4.Perform gag reflex (CN IX, X)
Results: Gag present
1. Inspect neck for, lumps, pulsations, symmetry
Results: Symmetrical, no lumps or pulsations
2. palpate trachea midline by placing index finger in sternal notch, and slip it off to each side.
Results: Trachea midline
3. Palpate occipital, post auricular, preauricular, tonsillar, submandibular, submental, superficial cervical, posterior cervical, deep cervical, and supraclavicular nodes bilaterally.
Results: Occipital, post auricular preauricular, tonsillar, submandibular, submental, superficial cervical, posterior cervical, deep cervical, and supraclavicular nodes non-palpable bilaterally.
Post-exam behaviors 1-6
- 1. Explained results of exam to patient
- 2. Cleaned up post exam
- 3. Performed exam in head to toe sequence
- 4. Performed exam in appropriate time frame
- 5. Adhered to principles of infection control
- 6. Provided safe environment throughout exam
Pain- 8 Health assessment questions
- 1. Location (be specific and anatomically correct)
- 2. Character or quality (describe)
- 3. Quantity or severity (Rate pain using pain scale)
- 4. Timing (when does the problem happen? How long does it last?)
- 5. Setting (Where does the problem happen?)
- 6. Aggravating or Relieving factors (What makes it feel worse or better? Include any medications taken)
- 7. Associated Factors (what else happens at the same time as the problem?)
- 8. Patient's perception of illness (What does the client think the problem is?)