Assessment

Introduce yourself to the patient. Correctly identify the patient utilizing two identifiers. For example, ask for the patient's name and date of birth. Make sure to provide privacy. Verbalize and describe all assessment findings. Take a general survey of the patient's overall status. Take vital signs, heartrate, blood pressure, temperature, pulse ox, and respiratory rate. You can verbalize this in your demonstration. Perform hand hygiene and don gloves. With the patient seated, examine the head and face.

Okay, I'm going to palpate here.

Next, examine the eyes. Check the conjunctiva and sclera. Assess eye symmetry.

Okay, I'm going to shine this light in your eyes if you would look just straight ahead and don't blink for me.

Test eye function by assessing PERRLA.

The other eye. Okay, thank you.

Check vision with the Snellen Chart.

You just put your hand over your eye and take a look and please read out the smallest line that you're able to see.

L-P-E-D.

That is wonderful. Switch eyes for me. We'll do the same thing over again, the lowest line.

F-E-D.

Next, examine the patient's mouth. Observe the color of the lips and moistness.

Would you open and close your mouth for me?

Inspect the teeth and gums. Assess buccal mucosa and palate.

Close, please. Looks good. May I get you to open now? You don't have to stick your tongue out at this point. I'm going to shine a light in your mouth.

Examine the tongue. Examine the uvula. Examine the tonsils.

Alright, now you stick your tongue out and say, "ah."

Ah.

I'm going to stick this tongue blade down, check your gag reflex. Try to cough. Alright, great.

Next, examine the patient's ears.

Okay, so I'm going to take a look at your ears first.

Okay.

Look inside the ears.

Can I get you to turn your head for me, please?

Which side?

This side here.

Assess ear discharge and tympanic membrane. Evaluate hearing using the whisper test.

Okay, now I'm going to do the whisper test. I'm going to whisper in your right ear first.

Okay.

And if you could just repeat back the three words that I said, okay?

Okay. Football. Sports car. Basketball.

Awesome. And I'm going to come around on your other side.

Okay. Apple. Banana. Grapes.

Awesome. You can hear very well.

Next, conduct the Weber and Rinne tests comparing bone conduction of sound to air conduction.

Can you hear it better here or here?

Second.

Okay.

The Rinne test is conducted on either side of the head, while the Weber is conducted on the forehead.

Okay, can you hear better here, or here?

Second.

Okay. If you could tell me if you can hear, is that good?

Yes.

Okay.

Next, examine the nose. Check septum and inside the nostrils. Check the patient's sense of smell.

Will you please close your eyes? And then I'm going to test your sense of smell. I'm going to put this right underneath your nostrils, and if you can let me know the scent that you're smelling.

Mint.

That is great. Awesome job.

Palpate the sinuses and nose and assess symmetry.

I'm going to be touching here for your sinuses. Does that feel uncomfortable?

No, it's fine.

Okay. So I'm going to continue with the examination of your neck.

Next, palpate lymph nodes. Observe and palpate the trachea and neck. Check for Jugular Venous Distension. Check the neck's range of motion.

And so now we're going to test your range of motion with your neck. If you could tilt your chin down to your chest. Okay, if you could go to the right and to the left. And if you could go backwards. Great job. Now if you put your head back in the position in which we started. And now I'm going to offer a little resistance by putting my hand up against the direction in which you will move your head for resistance, okay? So try to fight me back, if you could come down. Good job. We're going to go this way. Good job. This way. Alright. And if you could go backward. Alright, good job.

Check shoulder shrug with resistance.

Now I'm just going to test your shoulder strength. I'm going to put my hands on your shoulders and I want you to shrug your shoulders up and meet with resistance. Good job.

Next, inspect the patient's back. In a clinical setting, have the patient untie their gown in order for their back to be inspected. Examine their back and posterior chest. Note the skin, thoracic shape, shoulder symmetry, and muscle development.

I'm going to have you take some nice, easy breaths for me each time that I move the stethoscope, okay? And I'll cue you off, alright? Go.

Auscultate lung fields, anterior and posterior. Assess respiratory expansion level and symmetry. Ask about coughing. Palpate the thorax. Assess work of breathing. Next, examine the patient's chest. Check their pulses. Palpate the carotid and temporal pulses bilaterally. When assessing the carotid arteries, do not press on the carotid artery on both sides of the neck at the same time. This may cause the patient to feel lightheaded or dizzy or possibly faint. Auscultate heart sounds. Auscultate lung fields in the anterior chest wall as well.

I'm going to check your pulses.

Check pulses in the arms, legs, and feet, including radial, femoral, posterior tibial, and dorsalis pedis.

Okay, I'm going to come around to the other side and check your other two pulses. Thank you. We're good.

Check capillary refill on fingernails and toenails.

I'm going to check your nails here. I'm also going to check for capillary refill. That looks amazing. Okay, Michael, I'm going to have you lie back, please. If you would just put your feet there. I'm going to prop this pillow up just a tad bit for you. Okay, lay back. Alright. I'm just checking bilateral pulses behind the knees. Alright, good. And I'll just be checking the capillary refill, bilaterally, both your feet. Please lift up your shirt. I'm going to take a look at your stomach, okay?

Inspect the abdomen. Listen to the four quadrants of the abdomen for bowel sounds. Palpate the four quadrants of the abdomen for pain or tenderness.

Have you had any problems with your bowels and/or bladder?

No.

Alright. Can you tell me the last time you've had a bowel movement?

This morning.

This morning? That's great.

Next, ask the patient to rotate their ankles.

Good job. Can you go in the other direction?

Assess range of motion and strength.

Awesome. Can I have you swing your legs in this direction for me, please, and if you could scoot to the end of your chair? Please hold your arms out for me.

Assess range of motion and strength.

Hold your arms out to the side and put them in a circular motion going forward. Alright, and let's go backwards. Do the same thing. Thank you very much. And now, can you extend your legs one at a time?

Assess orientation status: alert and oriented times three. Assess gait, check coordination. Assess reflexes. Check Glasgow Coma Scale: Eye Opening Response, Verbal Response, Motor Response. Skin, hair, and nails assessment includes: checking skin turgor; checking for lesions, abrasions, rashes; checking for tenderness, lumps, lesions; checking if patient is pale, clammy, dry, cold, hot, flushed; checking bony prominences for skin breakdown; checking for cracking or denting in nails; checking for missing or thinning hair.

And my last question, I just wanted to know, have you been experiencing any pain anywhere in your body?

No.

No pain at all? Alright, well that ends our assessment. Thank you.