Head to Chest Script

Section 1: Introduction *Knock* Hello my name is Maria, and I am going to be your student nurse today. I am here to perform a head to chest assessment that is going to take me about twenty minutes is that ok? Ok great, please excuse me while I perform hand hygiene and then I will close the curtain for privacy. Can you please tell me your full name and date of birth? Ok great I am just going to check your wristband to make sure the information is correct. It is, do you have any food or medication allergies I should be made aware of? Ok, and on a pain scale from 0 to 10, 0 being no pain and 10 being the worst pain you’ve ever felt, what is your pain level today? Section 2: General Appearance My patient is showing no signs of acute distress. - My patient’s facial expression is appropriate for the situation - My patient’s mood is comfortable and cooperative - My patient’s speech is clear and understandable. Do you mind if I ask you a few more questions? - Can you please tell me your full name and date of birth one more time? - Do you know where you are right now? - Do you know why you are here? - And can you please tell me what year it is? My patient is alert and oriented to person, place, time, and event. Section 4: Skin and Nails I am now going to inspect my patients skin and nails. - My patients skin color is consistent with their ethnicity - There are no lesions, wounds, or incisions noted - My patient’s nails are pink in color, round, and slightly curved I am now going to test for capillary refill by pressing down on my patients nail bed for a few seconds - Capillary refill is 2 seconds Section 5: Head, Face, and Neck - My patients facial structure is symmetrical I will now perform hand hygiene and don gloves in order to inspect my patients head - Upon inspecting my patients head there are no lesions or infestations noted Section 6: Eyes I am now going to inspect my patient’s exterior ocular structure. - There is no discharge or redness noted I am now going to inspect my patient’s conjunctiva and sclera by pulling down the lower eyelid - My patient’s conjunctiva is pink and the sclera is white I am now going to inspect my patient’s pupils, excuse me do you mind looking straight forward for me - My patient’s pupils are 2 millimeters in size, equal, round, and reactive to light I am now going to test for accommodation, can you please follow my pen light with your eyes? - My patient’s eyes accommodate Section 7: Ears I am now going to inspect my patient’s external auditory meatus on both sides. - There is no discharge noted I am now going to assess my patients hearing by performing the whisper hearing test. I have given my patient instructions that I will stand two feet behind them, and on command they will cover the ear not being tested and will have to repeat the number letter sequence that I whisper to them. - Excuse me, do you mind closing your right tragus with your finger and repeating after me? - Ok great, now can you please close your left tragus with your finger and repeat after me? My patient passed the whisper hearing test. Section 8: Nose I am now going to inspect the internal structures of the nose by looking into each nostril with my penlight - No deformities, no asymmetry, and no inflammation noted I am now going to assess my patient’s bilateral patency - Excuse me, do you mind closing your left nostril and breathe in through your nose for me? - Great, now can you close your right nostril and breathe in through your nose for me? Bilateral patency noted, no drainage noted Section 9: Mouth and Throat I am now going to inspect my patient’s lips, tongue, and gums. - Excuse me, can you open your mouth and say “ah”? My patient’s lips, tongue, and gums are pink and moist Section 10: Respiratory System I am now going to inspect my patient’s respiratory system starting with the anterior chest. - No accessory muscle use noted I am now going to auscultate my patient’s anterior lung sounds in a SIDE TO SIDE PATTERN “NO ADVENTITIOUS BREATH SOUNDS NOTED ON EITHER SIDE” Section 11: Cardiovascular System I am now going to assess my patient’s cardiovascular system starting with the carotid pulse. I am going to palpate the pulse on both sides for 30 seconds then times that number by 2, if the beat is abnormal I will auscultate for 1 minute. - The carotid pulse has a force of 2+ I will now assess my patients radial pulse on both sides. I am going to palpate the pulse on both sides for 30 seconds then times that number by 2, if the beat is abnormal I will auscultate for 1 minute. - The radial pulse is 80 beats per minute, with a regular rhythm, and a force of 2+ I am now going to auscultate the cardiac areas with the diaphragm of my stethoscope - Aortic Artery right sternum border second intercostal space - Pulmonic Artery left sternum border second intercostal space - Erb’s Point left sternum border third intercostal space - Tricuspid left sternum border fourth intercostal space - Mitral left sternum border fifth intercostal space “no abnormal sounds noted” I am now going to auscultate the cardiac areas with the bell of my stethoscope - Aortic Artery right sternum border second intercostal space - Pulmonic Artery left sternum border second intercostal space - Erb’s Point left sternum border third intercostal space - Tricuspid left sternum border fourth intercostal space - Mitral left sternum border fifth intercostal space “no abnormal sounds noted” Section 12: Closure Thank you for allowing me to perform a head to chest assessment on you. - Before I leave I am going to reassess your pain level, on a scale of 0 to 10, 0 being no pain and 10 being the worst pain you have ever felt what is your pain level? I am now going to make sure my patients bed is in the lowest position possible, I am going to make sure the bed is locked, and I am going to make sure both side rails are up. - “here is a call button in case your pain level changes or you need anything else” - Thank you again for allowing me to perform this assessment I am now going to perform hand hygiene once more before leaving my patients room.