- Hello.
Welcome to Santa Fe College Nursing Simulated Lab.
My name is Professor Sandra Milner,
and today, I'm gonna be demonstrating
a complete head-to-toe physical assessment.
The video is gonna be broken up into two parts.
Part one is gonna include assessment of the patient's head,
their upper torso, their abdomen,
and questions related to the urinary system.
Part two is gonna include the patient's
lower extremities and their back.
The head to toe physical assessment
follows a systematic approach.
You go from the head to toe, and
then the back is assessed last.
You adjust your assessment based off of
the patient's developmental level and their cognitive level.
There are a few things you assess throughout.
This includes skin and hair distribution
and then also the patient's speech,
whether they have purposeful movements,
and whether they are able to follow
simple versus more complex commands, so if they're able
to follow one-step versus two step commands.
If you ask the patient to reach, to turn over and reach
for the rail, are they able to do those two commands?
Vital signs are usually completed
at certain times during the day.
The only time you complete vital signs
with an assessment is if your patient is having
an acute change or problem with a specific system.
Good morning Ms. Griego,
how are you doing today? - Good.
- Okay, my name is Sandra,
I am your nurse today. - Okay.
- And the first thing I'm gonna do
is complete a head to toe physical assessment.
First I'm gonna wash my hands, or sanitize.
While I am cleaning my hands, I am gonna do
a general survey of the room so I can see that she has
a suction canister, she has oxygen,
we have an IV pole, I am checking the bed.
The bed is locked, she is in the
lowest position and two side rails are up.
Okay Ms. Griego, we're gonna go ahead and raise your bed
so I don't hurt my back, and I'm also gonna lower this rail.
(clanking of bed rail)
How are you doing today? - Good.
- Can you tell me your first and last name?
- Casey Griego.
- And I'm gonna check her arm band.
And what is your date of birth?
- May second.
- Okay perfect, and do you know where you are?
- I'm at the hospital.
- And do you know why you are here at the hospital?
- Um, I've been having some stomach pain.
- Okay, and are you in
any pain right now? - No.
- Okay, and so on a scale of zero to 10,
with 10 being the worst pain and zero being no pain,
could you rate your level of pain?
- I'd say it's a zero.
- A zero, okay, wonderful.
And can you tell me what year it is, or what month?
- It is March.
- March, okay, and what year? - 2017.
- Okay perfect, okay, so now I'm gonna take a look
at your face, and I do not see any facial drooping.
Can you smile for me?
Okay, perfect, so the first thing
we're gonna do is take a look at your nose.
You can just look up, and can you breathe through your nose?
Perfect, any problem breathing through either side?
- No.
- Wonderful, and can you open up your mouth for me?
I'm gonna shine my light, I'm looking
at her teeth, and can you say "ah"?
- Ahhh.
- Perfect, and I see her uvula rise,
now what we're gonna do is look at your ears.
Do you wear glasses?
- Yes.
- Okay and do you wear hearing aids?
- No.
- Okay, I'm gonna take a look at her ears.
Make sure you pay special attention to the top part
of her ear where you might have oxygen tubing
and can you turn to the other side for me?
Perfect, and I do not see any sores or lesions.
If your patient is not able to turn their head,
you want to, when you are on the other side of the bed
you want to do a better assessment of that side of the ear.
I'm also gonna take a look at your head.
This is a normal shape (laughing)
and do you have any pain on your head?
- No.
- No, where I was pushing?
You have even hair distribution for a female patient.
Can you turn to that side for me?
I'm gonna take a look at the back of her head
and I do not see any hair loss or breakdown of the skin.
You can also take a look at the back of her head a little
better when she rolls over to the side.
I'm also gonna take a look at your neck
so if you could just look slightly that way,
and I do not see any jugular venous distention.
So now we're gonna look in your eyes and what I'm looking
for is the change in pupil shape so I wanna see her pupils,
both sides, constrict when I shine the light.
And then we're gonna look for accommodations.
So we're looking for PERRLA pupils are equal, round,
and reactive to light, and accommodation.
So I'm gonna shine the light first in this side,
just look straight ahead please.
And you need the room somewhat dim.
And then what I want you to do is take a look at the top
of the wall and now look at my pen.
Perfect, and when she does that you should,
her pupils should constrict when she looks closer.
So now we're gonna go ahead an assess your arms.
So I'm looking at skin, I see you have an IV here.
- Mhm.
- Any pain or tenderness? - No.
- Okay, and I see it is within date,
so I'm gonna look at her skin,
I'm looking at bony prominences.
I do not see any skin break down.
You can put that arm down.
I'm gonna look at this side, and if I cannot see very well,
you do wanna go to the other side of the bed.
Okay, and no IV.
I'm gonna check your pulses.
And you always check pulses bilaterally,
and so those are two plus and equal.
I'm gonna check cap refill, less than two seconds.
And then can you bend your arms for me?
And then, okay, and again? Good.
And then can you squeeze my hands?
Perfect, so she has normal strength
and a full range of motion.
Next what we're gonna do is go ahead
and listen to your heart and lungs.
So we have the mannequin here to demonstrate the correct
positioning for listening to heart sounds.
What you wanna do is you wanna find the angle of louis
on your patient, which is the little notch,
if you go to the left or the, to the right, or
the left side, you'll find the second intercostal space.
On the right side of the patient
you'll best hear the aortic valve.
That is in the second intercostal space,
right sternal border.
If you move over to the left sternal border,
second intercostal space, is where
you'll hear the pulmonic valve best.
If you go down one rib, into the third intercostal space,
this is where you'll hear the ERB's point.
If you go down to the fourth or fifth,
depending on your patient, intercostal space,
left sternal border, that is where
you're gonna hear the tricuspid valve best.
In the fifth intercostal space, midclavicular line,
so that's the middle of the clavicle,
right in that midclavicular line, fifth intercostal space
is where you're gonna hear the point
of maximal impulse, which is your mitral valve.
Normally you would listen under
the patient's gown but for the purpose of the video
we are listening over the patient's gown.
Aortic...
Pulmonic...
ERBs...
Tricuspid...
and mitral.
And then I'll switch.
Okay, very good, and now I'm gonna listen
to your lung sounds, and you wanna listen through
a whole inspiratory and expiratory cycle.
And you always compare side to side.
Can you take a deep breath, in and out?
(deep breathing)
And I'm gonna listen under your arm over here.
And then under this arm, okay, excellent.
So now I'm gonna go ahead and listen to her abdomen
and what you wanna do is lower the sheets
and lift the patient's gown up.
And again, we're not, we're gonna be listening over clothes
for the purpose of the video but you would always move
the patient's clothes out of the way.
So the first thing I would do is inspect the abdomen
and then I will listen and then palpate.
You listen in each four quadrants.
Okay.
And you said you're not experiencing
any pain right now, correct?
- Correct.
- Where was the pain before?
- Kinda just all over.
- All over, okay.
Let me know if anything hurts,
I'm just doing light palpation.
And when was your last bowel movement?
- Yesterday.
- Okay, I do not feel any
obvious masses or hepatic distention.
And any trouble peeing?
- No.
- Okay, normal color, no burning, no pain?
- No.
- Okay, any bowel movement changes?
- No.
- No color changes, not very hard or too soft?
- No.
- Okay, wonderful.
And that completes the end of part one.
So stick around for part two where we're gonna be assessing
the lower extremities and the patient's back.