NR 304 Head to Toe Assesment Script

Student Name

Chamberlain University

NR-304: Health Assessment II

Prof. Name

Date

Head-to-Toe Assessment

Health Assessment 2

Introduction

Before starting the examination, the nurse greets the patient, introduces themselves as a student nurse, and performs hand hygiene. Patient identification is verified by confirming the first and last name and date of birth. Privacy is ensured, and the nurse explains the procedure, including its purpose and expected duration of 20–30 minutes. The patient’s consent is obtained, and allergies are reviewed. Pain is assessed on a 0–10 numerical rating scale. Once safety measures are in place, the nurse adjusts the bed to hip level and lowers the side rail to begin the assessment.

General Appearance

The patient does not exhibit any acute distress and maintains a calm demeanor. Facial expression is relaxed, and speech is fluent and clear. Mood and affect are appropriate to the situation. To assess orientation, the nurse asks the patient to state their name, location, time, and the reason for their visit. The patient is alert and oriented to person, place, time, and situation (A&O ×4).

Skin and Nails

The patient’s skin tone is consistent with their ethnicity and free from rashes, lesions, or open wounds. On palpation, the skin of both upper and lower extremities is warm and equal in temperature bilaterally. Nails are pink with a normal curvature of approximately 160°. Capillary refill is brisk at less than two seconds, indicating good peripheral circulation.

Head, Face, and Neck

The head is normocephalic, and facial features are symmetrical. After performing hand hygiene and donning gloves, the nurse inspects and palpates the scalp, noting that the hair is evenly distributed, clean, and free of infestations or lesions. Gloves are removed, and hand hygiene is repeated. The trachea is midline with no visible or palpable masses.

Cranial Nerve Assessment (Head, Face, and Neck)

Eyes

The external ocular region shows no discharge, redness, or swelling. The sclera is white, and conjunctiva is moist and pink. Pupils are equal, round, and measure approximately 3 mm. Pupillary light reflex is brisk bilaterally, and accommodation is demonstrated with convergence and constriction when following a penlight. No nystagmus is observed.

Cranial Nerve Assessment (Eyes)

Ears

The external auditory canals are clean, with no evidence of discharge or swelling. The whispered voice test, conducted at a distance of two feet, is correctly repeated bilaterally, indicating intact cranial nerve VIII (Vestibulocochlear).

Nose

Nasal passages appear symmetrical, with no deformities, inflammation, or abnormal drainage. Bilateral patency is confirmed as the patient alternately occludes each nostril while breathing through the other.

Mouth and Throat

The lips, gums, and tongue are moist and pink. The uvula and soft palate elevate symmetrically at the midline during phonation, confirming intact cranial nerves IX (Glossopharyngeal) and X (Vagus). The gag reflex is present when assessed with a tongue depressor. Cranial nerve XII (Hypoglossal) is intact, as the patient clearly articulates “light, tight, dynamite.”

Respiratory System

Respirations are unlabored and symmetrical, without accessory muscle use. On auscultation, vesicular and bronchovesicular breath sounds are heard in appropriate lung fields, with no adventitious sounds such as wheezes, crackles, or rhonchi.

Cardiovascular and Peripheral Vascular

Carotid, radial, posterior tibial, and dorsalis pedis pulses are palpated bilaterally with a regular rhythm, strength of +2, and a rate of 72 beats per minute. No edema is observed in the extremities. Auscultation with the diaphragm and bell of the stethoscope across the aortic, pulmonic, Erb’s point, tricuspid, and mitral areas reveals normal heart sounds with no murmurs.

Gastrointestinal and Urinary

The abdomen appears flat and symmetrical. Bowel sounds are normoactive in all four quadrants upon auscultation. Light palpation reveals no tenderness, rigidity, distention, or palpable masses. No urinary concerns are reported.

Musculoskeletal

Bilateral inspection of the elbows, wrists, knees, and ankles shows no swelling, deformities, or visible masses. The patient demonstrates active range of motion in all major joints, including flexion, extension, pronation, supination, dorsiflexion, plantar flexion, inversion, and eversion. Strength is graded 5/5 against resistance. Sensation is intact with normal two-point discrimination. The patient demonstrates a steady gait while ambulating in a straight line.

Closure

Pain is reassessed using the 0–10 numerical scale. The bed is lowered to its safest position, side rails are raised, and the wheels are locked. The nurse places the call bell within the patient’s reach, addresses any remaining questions, thanks the patient for their participation, and performs final hand hygiene.

References

Jarvis, C. (2020). Physical examination and health assessment (8th ed.). Elsevier.

Lewis, S. L., Bucher, L., Heitkemper, M. M., Harding, M., & Kwong, J. (2023). Medical-surgical nursing: Assessment and management of clinical problems (12th ed.). Elsevier.

NR 304 Head to Toe Assesment Script

Potter, P. A., Perry, A. G., Stockert, P., & Hall, A. (2021). Fundamentals of nursing (10th ed.). Elsevier.