NR 304 Health Assessment II Head to Toe Assessment Final Script
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Course
Nursing course
Institution
Nursing Course
NR 304 – Health Assessment II
Head to Toe Assessment Final Script
Introduction & AIDET
***Knock Knock***
Me: May I come in?
Patient: Yes.
Me: Hi, my name is (insert name) and I am a student nurse at Chamberlain University, and I
have physician’s orders to perform a head to toe assessme...
NR 304 – Health Assessment II
Head to Toe Assessment Final Script
Introduction & AIDET
***Knock Knock***
Me: May I come in?
Patient: Yes.
Me: Hi, my name is (insert name) and I am a student nurse at Chamberlain University, and I
have physician’s orders to perform a head to toe assessment on you which will take about
15-20 minutes, is now a good time?
Patient: Yes.
Me: I am going to start off with providing you with some privacy by closing off these curtains
and taking care of my hand hygiene.
close curtains
perform hand hygiene
put on gloves
Me: Can I get your name and date of birth please?
Patient: (Patient Name); June 27, 1999
Me: Okay, let me just check your wristband to verify.
check wristband
Guadalupe Jaime, June 27, 1999
Okay Ms. Jaime, are you allergic to any:
food,
medications
shellfish
iodine/betadine,
latex,
tapes or any other adhesives?
Patient: No.
Me: And are you in any pain today?
Patient: No.
Me: Okay, do you know where you are Ms. Jaime?
, Patient: Chamberlain University
Me: Okay, do you know what year it is?
Patient 2019
Me: And do you know who our current president is?
Patient: Donald Trump
Me: Patient is alert and oriented (x4)
Speech is clear and clothing is appropriate to time and place.
General Appearance
Me: Okay, we’re gonna go ahead and move on to your general appearance.
look at the patient
Posture is erect.
Skin is appropriate to age.
Skin color is appropriate to ethnicity.
No signs of acute distress.
Nutrition is adequate.
Mood and behavior are appropriate to situation.
And clothing is appropriate to situation as well.
(No visible devices or equipment being used.)
Vital Signs
Me: I will now be taking your vital signs.
check temperature
o before checking the temp, ask if patient had anything hot or cold to drink,
or smoked in the last 30 mins
check the pulse oximetry
take the blood pressure
o ask if patient knows their usual blood pressure measurement
check respirations
o count for 30 seconds and multiple by 2
Skin & Nails
Me: I’m gonna go ahead and start with your skin.
Skin color is appropriate to ethnicity.
There are no signs of lesions, incisions, wounds, rashes, and no tattoos visible.
I’m gonna go ahead and check for your temperature.
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