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Health Assessment (NR304) Head To Toe Return Demonstration

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John Marsh
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Chamberlain College of Nursing

Health Assessment (NR304)

Head to Toe Return Demonstration

Introduction
*Knock, close the curtain, perform hand hygiene
● Hello, my name is Sara and I will be your Nurse for today.
● Can I get your name and date of birth?
● Do you have any allergies?
● Do you know where we are right now?
● What brings you in today?
● Can you tell me the day of the week?
● On a scale of one to ten, with zero being no pain and ten being the worst possible pain,
how would you rate your pain?
● So, I am here to do a head to toe assessment. This will take me between 15 to 20
minutes. The assessment is just for me to get a better understanding of your health
overall.
● During the assessment, I will be asking you questions, touching (palpating) you, and
listening using my stethoscope. If at any time you have any questions, concerns or if I
elicit any pain feel free to tell me.
● Do you have any questions for me so far?
● If you don’t have any questions, we will go ahead and get started.
● PUT ON GLOVES
Vital Signs
● I’m going to start by taking your vitals.
● Did you smoke or drink anything hot or cold in the past 30 minutes?
● Do you have an AV fistula, mastectomy, or nailpolish on?
○ To take oral temperature, I’d place the thermometer in the sublingual pocket
underneath the tongue.
○ Do you prefer an arm for blood pressure? Do you know your baseline BP?
■ I’ll make sure that the cuff size is appropriate and wrap the cuff snugly
around the patient’s arm; 1 inch above the antecubital space and center
the bladder over the brachial artery.
■ Now I will palpate the brachial pulse and once I find it I will place the
diaphragm of my stethoscope on it.
■ I will inflate the cuff until I could no longer hear the pulse and then inflate
it 30 mmHg above that number.
■ Then I would deflate the cuff at a rate of 2-3 mmHg per second and note
the systolic and diastolic values.
● Now I will take your pulse and count respirations.
● For oxygen saturation, I would make sure there is no nail polish on the finger and place
the pulse oximeter on the finger.
Head, Neck, Face
● Can you raise your eyebrows, smile, frown, puff your cheeks, and stick out your tongue.
● I will inspect and palpate your head.
○ Do you have any pain or tenderness?
● Can you clench your jaw and do not let me open your mouth.
● I’ll be lightly touching your face with this cotton swab while your eyes are closed and
have you tell me when you feel the touches.
● Can you turn your head towards my hand?
● Now shrug your shoulders.
● Inspect and palpate neck

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Health Assessment (NR304) Head To Toe Return Demonstration

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