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Full Body Assessment Script
Fundamentals (NUR155)
Galen College of Nursing
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Full Body Assessment Script Introduce yourself Tell the patient what you are going to do and how long it will take. Wash your hands, put on gloves. Provide Privacy! Pull the curtain! Check patient armband Orientation questions Ask name and DOB. What is today? What is the year? Who is the president? Do you know why you are here? Head Scalp-Check for lumps, bumps, lesions, excessive oil, lice, coloration, and hair distribution Eyes- Sclera white, conjunctiva pink. PERL (Pupils equal and reactive to light) Face- Check color, temperature, wetness/dryness, and injuries Mouth Is it moist and pink? Check integrity of teeth. Does the patient have dentures? Neck Check skin color, temperature and integrity Palpate bilateral carotid pulses separately. Are they present and equal? Check the trachea.. it midline with the supra sternal notch? Range of motion in neck. Move up/down-side to side Listen for crepitus Check the skin turgor on the clavicle. Does it go back into place or stand up? Thoracic Front Check skin color, temperature, and integrity
Check the shape of the chest.:2 ratio, no barrel chest AUSCULTATE lung nodes. Ask your patient to take deep breaths in and out. Thoracic Back Check bilateral lung expansion. Check to see if both lungs are inflating equally by placing both hands on back to see if they move apart and together. Check Spinal alignment Check the sacrum for skin integrity AUSCULTATE lung nodes Cardiac Find the suprasternal notch (angle of Louis) Auscultate
- Aortic valve- 2nd intercostal space; right sternal border
- Pulmonic valve-2nd intercostal space, left sternal border
- Tricuspid valve-4th intercostal space
- Midclavicular-5th intercostal space a. The mitral valve is located here. Assess the apical pulse x1 minute.
Check bilateral femoral pulses. Are they present, strong, and equal?
Legs Check skin color, temperature, edema, and integrity. Check hair growth on both legs. Check range of motion in legs, feet ankles plantar flexion/dorsiflexion (Step on the gas/toes to nose) Bend legs at knee. Note: any pain or tenderness. Listen for crepitus. Feel for resistance Palpate bilateral popliteal pulses. Are they present, strong, and equal? Palpate bilateral posterior tibial pulses. Are they present, strong, and equal? Palpate bilateral dorsalis pedal pulses. Are they present, strong, and equal? Check skin integrity on heels and sole of foot. Check capillary refill in toes 2-3 seconds on both feet. Ask your patient Can you sit on the side of the bed? Are you able to stand? Can you take 4-5 steps? Note: if gait is steady or unsteady At the end of your assessment Thank the patient. Ask if they need anything Make sure they have the call light. Open the curtain. Clean stethoscope. Remove gloves. Wash your hands.
Full Body Assessment Script
Course: Fundamentals (NUR155)
University: Galen College of Nursing
