Intro:

1.​ Knock
2.​ Hand Hygiene
3.​ Provide Privacy
4.​ Hello, My name is ___________ I’m going to be your nurse;
a.​ May I please have your name and DOB. (x1)
b.​ Do you know where you are? (x2)
c.​ Do you know what month it is? (x3)
d.​ Do you know why you're here? (x4)
5.​ Okay now I’m going to have you take off your clothes and put on a gown
6.​ I’m going to give you this sheet to cover the areas I won't be examining yet!
Skin & Nails
1.​ Skin is normal for ethnicity
2.​ Skin is warm, dry, intact
3.​ Turgor; recoils immediatley
4.​ Nails shape looks great, nails are smooth & pink
a.​ NO clubbing or deformities noted.
Head
1.​ Head is normocephalic, symmetrical and in proportion to body
2.​ The scalp is clean and intact, no lesions, masses or infestations noted.
3.​ Facial features symmetrical, NO involuntary movements or drooping noted.
Eyes
1.​ Eyes symmetrical and aligned
2.​ Eyebrows and eyelashes evenly distributed
3.​ Eyelids smooth without redness, swelling or lesions
4.​ Conjunctiva pink and moist
a.​ Sclera White
b.​ Cornea Clear
c.​ Pupils Equal
d.​ Round and reactive to light and Accomodation (PERRLA)
i.​ NO discharge noted (Cranial Nerve III intact)
 5.​ Convergence
a.​ Focus on my penlight
b.​ Slowly more it toward nose
c.​ Keep looking at light
d.​ Eyes are smooth and symmetric

6.​ 6 Cardinal Positions

*Symmetrical alignment, smooth movement (Cranial nerve III, IV, and VI intact)

Visual Acuity (Snellen Chart)

1.​ Move about 20 ft
a.​ Cover one eye and read to the smallest line
b.​ Cover the other eye read to the smallest line
i.​ Cranial Nerve nerve II intact
Ears (NO Gloves NEEDED)
1.​ Ears are symmetrical and aligned with the outer canthus of eyes. Skin intact
without redness, lesions or drainage.
a.​ External canal clear.
b.​ Mastoid process is non tender to palpation.
c.​ No swelling or deformities noted.
2.​ Whisper Test
a.​ I’m going to have you cover one ear and while I’m one feet away 2-3 words
(Dog and Cat)
b.​ Okay, now cover the other ear (repeat) (Red and Blue)
i.​ Cranial Nerve VIII Intact

Nose
1.​ Apply gloves
2.​ Inspect and palpate external nose
a.​ Nose is midline and symmetrical
3.​ Get pen light (look in nose)
a.​ No lesions no growths; Pink and moist
4.​ Nasal Patency
a.​ Cover one nose (breathe)
b.​ Cover other side (breathe)
5.​ Palpate frontal and maxillary sinuses (do you feel any tenderness or pain?)
Mouth
​ TAKE NEW GLOVES and PENLIGHT OUT NOW
1.​ Okay I’m going to check the mouth now; I’m inspecting the lips, oral mucosa,
hard and soft palate, gingivae, and teeth. Okay color, moisture, and texture all look
good!

2.​ I’m going to be checking your uvula; Alright I’m going to have you say AHHHHH
and swallow
a.​ Cranial Nerve IX & X intact
3.​ Now I’m going to have you stick out your tongue (use your tongue blade)
a.​ Cranial Nerve XII intact
b.​ Color and moisture look great!!
c.​ NO signs of edema
REMOVE GLOVES!!
4.​ Is it okay if I just palpate your jaw? Okay, perfect! Okay now I need you to clench
your jaw
a.​ Cranial Nerve V intact
Inspect and Palpate Lymph Nodes
-​ You're gonna let me know if you feel any tenderness okay?
REMEMBER: P.P P.O.T.S S.A.P.S
1.​ Preauricular
2.​ Parotid
3.​ Post Auricular
4.​ Occipital
5.​ Tonsillar
6.​ Submaxillary
7.​ Submental
8.​ Anterior or deep cervical
9.​ Posterior cervical
10.​ Supraclavicular
*Okay, no enlargement or tenderness noted

Thyroid
1.​ Okay now I’m going to be checking the anterior
2.​ Now I will palpate you posterior thyroid
a.​ Can you swallow for me?
i.​ Size and symmetry (normal)
ii.​ No masses or signs of inflammation

Neck Mobility
1.​ Chin to chest
2.​ Chin to right shoulder
3.​ Chin to left shoulder
4.​ Right ear to right shoulder
5.​ Left ear to left shoulder
a.​ Okay, I am noting symmetry and no pain upon movement
Neurological Assessment
1.​ Can you smile for me?
2.​ Can you frown for me?
3.​ Can you wrinkle your forehead?
4.​ Can you puff out your cheek
a.​ Symmetrical and good motor function
b.​ Noting that Cranial nerve VII is intact
5.​ Can you shrug your shoulders for me? I’m going to be pushing down. I am going
to have you push against my resistance.
a.​ Asymmetrical and normal push against resistance
b.​ Noting that Cranial nerve XI is intact
6.​ Okay now I’m going to put my hand on your face and have you push against my
hand (left side)
7.​ Okay, now the right side!
a.​ Symmetry and Strength normal
Thorax Assessment
1.​ Now I’m going to have you sit and I’m going to look at your back
a.​ I’m just looking at your skin, bones, muscles of the spine, scapula and
overall back, and I’m just looking that you have even skin color, no lesions,
no rashes, normal use of your accessory muscles as well as normal lung
expansion and I see all of that is accurate with my assessment.
b.​ I’m going to now compare the front and back of your thorax and I’m noting
that its normal and I’m observing a 1:2 ratio
c.​ Now I’m going to palpate your spine and posterior thorax
i.​ Noting symmetry and normal lung expansion

2.​ Now I’m going to auscultate your lungs posteriorly …

●​ Noting lungs are clear; free of fluid; Normal use of accessory muscles
 3.​ Now I’m going to check the anterior part of your lungs (anteriorly)

*Skin normal; normal lung expansion; and proper use of accessory muscles

Carotid Artery Assessment

1.​ Okay now I’m going to put you into a supine position with the HOB elevated to 30
degrees
2.​ Now I’m going to palpate the carotid artery bilaterally; I’m going to be palpating
one at a time. (USE BELL OF STETHESCOPE)
a.​ Noting presence of a bruit

Cardiac Assessment
1.​ Okay you are in this position I’m just going to lower the bed to where you are
laying in a supine position.
a.​ Noting that the precordium is normal within the limits of proper contour,
pulsations, and heaves.
2.​ Okay now I’m going to locate your pulse by looking at the 4th and 5th intercostal
space left of midclavicular line.
a.​ No murmurs or extra heart sounds noted
3.​ Okay now I’m going to listen to your pulse for one minute (86Hr)
 a.​ Heart rate and rhythm normal
Abdominal Assessment
1.​ Okay you are going to stay in this position still and I am going to assess your
abdomen. Okay I’m going to cover your other body parts since this is all i’ll be
assessing.
a.​ Inspect abdomen
i.​ No rashes, lesions masses or scars
2.​ Okay I’m going to listen to your bowels using the diaphragm of my stethoscope
a.​ Start with the:

*Bowel sounds normal and present in all 4 quadrants

3.​ Now I’m going to auscultate for vascular pounds using the bell of my stethoscope;

*Noting Absence of Bruits

​
Upper Extremities
1.​ Okay, you can sit up now I’m going to just look at your arms and hands
a.​ Noting no redness, broken skin, rashes, or scars
2.​ I’m just going to feel your arms as well
a.​ Noting warm skin temp; dry intact; no tenderness; no edema
3.​ I’m going to check your radial and brachial pulse bilaterally as well
a.​ Noting 2+ (normal)
4.​ I’m going to check your capillary refill on your nails
a.​ Noting normal capillary refill (<3 seconds)
5.​ Okay, we're almost there. I'm going to ask you to extend your hands out… Okay,
now I’m going to have you turn your palms up and down super fast onto your
thighs
a.​ Noting Proprioception and Cerebellar function intact
6.​ Okay, now I’m going to have you squeeze my hands
a.​ Strength 5/5; and equal
7.​ Okay now i’m going to have you push against my hands
a.​ Strength 5/5; equal
8.​ Okay now pull your hands against my resistance
a.​ Strength 5/5; equal
Lower Extremities
1.​ Okay now I’m going to look at your legs
a.​ No redness, broken skin, rashes, scars, lesions, or edema
2.​ Okay I’m just going to palpate your legs bilaterally
a.​ Noting everything in normal range: Temp, skin dry, intact, non pitting and
grade force of 2+
3.​ Okay now I’m going to be palpating the popliteal, dorsal pedalis, and posterior
tibial pulses bilaterally.
a.​ Grade of force 2+
4.​ Okay now I’m going to have you lift one leg up at a time with your knee straight
a.​ Normal ROM
5.​ Okay now you're going to move your leg laterally with the knee straight to test. I
just wanna make sure that your hip is okay! (laugh but cry inside).
a.​ Normal ROM
6.​ Okay so similar to what we did before with your arms, I’m going to have you raise
your thigh up against the resistance of my hand.
7.​ Okay now outward
8.​ Okay now inward
a.​ Grade Strength is 5/5 and equal
9.​ Ask the patient to dorsiflex, plantar flex against resistance
a.​ Noting grade strength 5/5 and equal
10.​ Okay now lets sit up…….
11.​ Okay now I’m going to assess and grade the deep tendon patellar reflex bilaterally
a.​ Normal
12.​ Okay now I need you to stand…..
13.​ Okay walk over to that side for me
a.​ Noting regular gait, heel to toe motion; normal
14.​ Romberg Test
a.​ Stand with your feet together with your arms at your side
i.​ Patient is steady; no swaying noted; maintain stability
1.​ Negative.
15.​ Okay now you can sit back down, are you comfortable?!?!?!
16.​ Remove Gloves; if used
17.​ Hand hygiene
18.​ Document assessment findings