NR 304 Head to Toe Assesment Script

Student Name

Chamberlain University

NR-304: Health Assessment II

Prof. Name

Date

Head-to-Toe Health Assessment

Introduction

Before initiating the assessment, the nurse should approach the patient with professionalism and respect to establish rapport and ensure informed consent. The process begins with a polite greeting and confirmation of patient identity.

Example sequence:

• Knock gently before entering the room.
• Perform hand hygiene to prevent cross-contamination.
• Introduce yourself: “Hello, my name is Dana, and I am your student nurse today.”
• Verify the patient’s first name, last name, and date of birth for correct identification.
• Ensure privacy by drawing curtains or closing the door.
• Explain the procedure: inform the patient that a head-to-toe health assessment is required as per provider’s order, lasting approximately 20–30 minutes, and will include light touching and exposure.
• Ask for consent to proceed.
• Inquire about allergies to medications, food, or materials (e.g., latex).
• Assess baseline pain level: “On a scale from 0 to 10, with 0 being no pain and 10 being the worst pain imaginable, what is your pain level?”
• Adjust the bed to hip level for ergonomic safety and lower the side rail on your working side.

General Appearance

Upon observation, the patient displays no signs of acute distress. The facial expression is relaxed, and the mood and affect are calm and appropriate to the situation. Speech is clear and coherent.

To assess mental status and orientation:

NR 304 Head to Toe Assesment Script

Question	Expected Normal Response
Can you tell me your first and last name again?	States both correctly
Where are we right now?	Identifies location accurately
What time of day is it?	Provides appropriate time frame
Why are we here right now?	Explains purpose of visit

The patient is alert and oriented to person, place, time, and situation.

Skin and Nails

Inspection reveals skin coloration appropriate to ethnicity with no visible lesions, wounds, or incisions. Palpation of the upper and lower extremities bilaterally shows warm and evenly distributed temperature.

Nail assessment demonstrates pink nail beds, a slight curvature of approximately 160 degrees, and capillary refill under two seconds—indicating adequate peripheral perfusion.

Head, Face, and Neck

The patient’s facial features are symmetrical, and the head is normocephalic. The scalp is clean, hair is evenly distributed, and no signs of infestation or lesions are noted. The trachea is midline without palpable masses.

Cranial Nerve Assessments:

Cranial Nerve	Test	Expected Findings
V: Trigeminal	Motor: Have patient clench jaw; apply resistance to chin. Sensory: Touch face lightly with cotton ball, asking for recognition.	Strong, symmetrical jaw movement; intact sensation across face.
VII: Facial	Ask patient to close eyes tightly, raise eyebrows, smile, puff cheeks, and pout.	Symmetrical movements; no drooping or weakness.
XI: Spinal Accessory	Shrug shoulders and rotate head against resistance.	Full strength and symmetry noted.

Eyes

External ocular inspection reveals no redness, discharge, or swelling. The conjunctiva appears pink, and sclera is white. Pupils are equal, round, and approximately 3 mm in size, reacting briskly to light and accommodating with convergence on near objects.

Cranial Nerves III, IV, and VI (Oculomotor, Trochlear, Abducens) are assessed through the six cardinal fields of gaze—no nystagmus observed.

Ears

Inspection of the external auditory meatus shows no discharge. Whispered voice testing (with opposite ear gently occluded) from a distance of approximately 60 cm confirms intact cranial nerve VIII (Vestibulocochlear).

Nose

The nasal structures appear symmetrical, without deformities, inflammation, or drainage. Bilateral patency is confirmed by occluding one nostril at a time and asking the patient to inhale.

Mouth and Throat

The lips, tongue, and gums are moist and pink.

Cranial Nerve Assessments:

Cranial Nerve	Test	Expected Findings
IX & X: Glossopharyngeal & Vagus	Depress tongue, have patient say “ahh,” observe uvula rise; ask patient to swallow and speak.	Midline uvula movement; clear voice; effective swallow.
XII: Hypoglossal	Ask patient to say “Light, tight, dynamite.”	Clear articulation; tongue movements symmetrical.

Respiratory System

Inspection of the anterior chest shows unlabored breathing without accessory muscle use. Auscultation, performed in a side-to-side pattern, reveals vesicular and bronchovesicular sounds in appropriate anatomical locations, both anteriorly and posteriorly. No adventitious sounds (wheezes, crackles, rhonchi) are present.

Cardiovascular and Peripheral Vascular System

Carotid, radial, posterior tibialis, and dorsalis pedis pulses are regular in rhythm, +2 in strength, and approximately 72 beats per minute bilaterally. No peripheral edema is noted upon palpation.

Cardiac auscultation at the aortic, pulmonic, Erb’s point, tricuspid, and mitral sites—first with the diaphragm, then the bell—reveals normal heart sounds with no murmurs.

Gastrointestinal and Urinary System

With the patient supine, the abdomen appears symmetrical and flat. Bowel sounds are present in all four quadrants (RLQ, RUQ, LUQ, LLQ). Light palpation (1 cm depth) detects no tenderness, guarding, or masses.

Musculoskeletal System

Inspection of upper and lower extremity joints (major and minor) reveals symmetry, no swelling, and no deformities.

Joint Motion & Strength Testing:

Joint	Movements Tested	Strength Grade
Elbows	Flexion, extension, pronation, supination	5/5
Wrists	Flexion, extension, radial & ulnar deviation	5/5
Knees	Flexion, extension	5/5
Ankles	Dorsiflexion, plantar flexion, inversion, eversion	5/5

Bilateral upper and lower extremity strength is intact. Two-point discrimination from proximal to distal confirms sensory integrity. Gait assessment shows steady balance and coordination over a 10–20 foot walk.

Closure

Following the assessment, the nurse reassesses pain: “On a scale from 0 to 10, how is your pain now?” The bed is returned to the lowest position with side rails up and brakes engaged. The call bell is placed within reach, and the patient is invited to ask any questions. The session concludes with a polite thank-you and final hand hygiene.

References

Bickley, L. S., & Szilagyi, P. G. (2021). Bates’ guide to physical examination and history taking (13th ed.). Wolters Kluwer.

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