Head to Toe Exam By Carolyn Merriman, APRN, MS

[Music] hello my name is karellen Merryman and I'm one of the faculty at East Tennessee State University's College of Nursing

I'm going to demonstrate what a final head-to-toe exam looks like during this exam I will be doing the exam and also I will be verbalizing my findings you may

find in your course that you're required to verbalize your findings or that you're only required to document your findings hi my name is Carolyn Mariam

and I'm gonna be your nurse today can you please tell me your name sure it's Marci Smith hi Marci um is that okay if I call you Marcy sure okay thank you well today I need to do a

head-to-toe exam so I'll be checking eyes and ears your heart your lungs your abdomen and your muscle strength do you have any questions before we begin no I am you've already told me your name

will you please tell me what time of day it is sure it's morning time around 10 o'clock okay and will you tell me where you are today we're at ETSU okay thank you my patience alert and oriented times

three I think before we get started I'm gonna do your blood pressure do you prefer one arm over the other okay that's closest to our machine here

okay and let me just get a pillow so it's at arm yep so your arm is at heart length heart level all right I could do

this by electronic but I have a manual so that's what I'm going to do okay pal fighting your brachial artery that's why how I lined up this cuff it

was a hundred over sixty is that what it usually runs okay thank you all right so the next thing I want to do is just

start with your eyes and I see that your eyebrows are symmetrical your eyelashes are full your sclera is clear your conscience tie though let me

double-check that can you pull your lids down for me okay pink your eyes look moist your corneas

look also clear now I want to check your pupils to see their size just look straight ahead they're about a four on

both sides so they're symmetrical now I'm going to shine the light into your eyes just look straight ahead okay

excellent they constrict on each side at the same time when I put it in one it goes in the other now I want to check your eyes for accommodation so look straight ahead and when I put my pen light in front of you please look at

that okay look at the pen light okay so your eyes accommodate by constricting all right the next thing we're gonna do

is look at your ears okay so let's let's see your ears are even colored tanned there's no deformities that I can see

they're rounded in shape and there's no lesions on them no drainage from the internal ear same thing let's look round it on your right side even in color

tanned no lesions no deformities I don't see any kind of drainage coming from that ear now I need to just check out your mouth your lips are pink

they look pretty moist can you open your mouth please the upper part of your mouth your upper

palates are pink and moist inside of your cheeks pink and moist can you say ahh and can you stick your tongue out raise it up okay and ever it looks like

pink moist your teeth our and gums look healthy there's no missing teeth there's no cavities looking cavities your gums are not over

your your teeth alright so that looks like a pink moist and no lesions for your mouth alright next thing I'm gonna do is just check your neck and I'm

checking for the carotid pulse one at a time carotid pulses two plus which is normal while I'm here at your

neck I'm gonna check your trachea your trachea is midline and that's normal as well alright just gonna gently pinch up a little skin to check for turgor it is

brisk it snaps back quickly let me look at your arms now if you don't mind thank you alright we're really looking at the front side

of your arms and looking at the back side of your arms the color is even and tanned I don't see any vascularity or

bruising or any lesions cuts or scratches insect bites now I'm going to touch it with the back of my hand warm

dry and smooth texture on the anterior and posterior arms perfectly thank you alright so let me go ahead and look at

your hands nails are no clubbing left or right pressing down nails are firmly

attached the nails are rounded they're pink in color and the capillary refill is less than three seconds let me check

your radial pulses while I'm here radial pulses are two plus bilaterally let me check your hand grips if you'll squeeze

please okay excellent strength I would grade that five plus all right now what I'm going to do is if you don't mind we'll raise the blanket and I'm going to

check the skin and different things on the bottom alright so your skin I'm just looking first it looks even tanned like

tan color I don't see any lesions bruises vascularity on the front okay

looking on the back the same smooth texture skin is warm and it's dry on

both sides okay shut for edema here pressing five seconds no pretibial edema

let me check your pitas pulses dorsalis pedis pulses there two plus bilaterally okay checking the cap refill in your toes

less than three seconds can you press on my hands plantar flexion is five plus I'm going to go ahead and Reese Anna thighs my hands all right the next thing

we're gonna do is go to some of the core organs so we're gonna start with respiratory you can put your pants legs down so I'm gonna start with respiratory

and I'm just looking at your respiratory chest to make sure that you have even breathing will you take a deep breath please so I see a symmetrical rise and fall of your

chest now I'm going to measure the anterior to posterior diameter is about half but it's certainly less than transverse which is across so a P is

less than transverse next I'm going to listen to some breath sounds so I'm gonna listen to about six to eight on the front and then about eight on the back and then one underneath your right

arm okay every place every place that I put my stethoscope if you'll just take a deep breath okay okay you don't okay mm-hmm

okay if you don't mind to feel cover I'm going to go under okay can you use just this one yeah okay that's why I just want to make sure you're covered all

right so I'm going to do two sides underneath thank you perfect all right you've been covered out so anterior

breath sounds are present they're clear the predominant sound is vesicular there's no adventitia sounds no rales rhonchi or wheezing can you please turn

to the around thank you and we'll take this cover to cover your back try to keep your privacy alright can I'm just

going to move your hair if that's okay alright so I'm gonna start at the top if

you'll take a deep breath another one another one you're right yeah here all right now I'm

going to raise your shirt I've done four sites but I want to do a few more so do you mind uh putting this over your shoulder there you go all right another

one please another one good another one and one more all right that's perfect now what I want to do is just while your

arm is up I'm gonna do one underneath your arm okay take a deep breath and that's your lateral one all right so

we've done your respiratory the posterior and the lateral were also breath sounds breath sounds were present they were clear you can turn around now

there was no adventitious sounds wheezing rails are wrong chi in any of the areas all right so I think we'll do

next is we're gonna do the cardiac exam let me get set up here to help do that can I can you move your hair over that way okay so to do the cardiac exam first

thing I want to do is just look across your chest so I'm looking across I don't see any heaves I don't see any lifts now

I'm going to place my stethoscope on five different areas and then stop and do an apical pulse and then listen with the backside - that doesn't mean

anything is wrong I just need to listen carefully okay thank you okay second

intercostal space right sternal border is aortic second intercostal space left

sternal border is pulmonic third intercostal space left sternal border is herbs can you please cover yourself here

and we will keep you draped here okay this is the fourth intercostal

space left sternal border tricuspid fifth intercostal space midclavicular

line that's called the mitral I'm going to stay here for one full minute okay that's your heart rate was regular

and it was 66 okay now I'm going to go back and listen with the Bell mitral

tiffin or cast of space midclavicular line tricuspid fourth intercostal space

left sternal border we can go ahead and take the sheet down herbs third

intercostal space left sternal border pulmonic second intercostal space less

sternal border a or t'k second intercostal space right sternal border at each of the sites I heard a distinct

s1 and s2 it was a regular rate I didn't hear any extra heart sounds I didn't hear any splitting I didn't hear any murmurs so well the next part of the

exam is I'm going to go to your abdomen so if you want to we can keep this cover up and we'll keep you protected this way thank you for going back down in the bed

so you can go ahead and just expose whatever here we go thank you all right so I'm looking first down and across and

I'm looking for your contour your contour is flat there's no extra pulsations and no peristalsis that I see you're emboli kisses midline there's no

drainage there's no redness now I'm going to listen with my stethoscope in each of the four quadrants bow sounds are present in all four

quadrants and they're normal active okay now I'm going to just lightly press on your belly with one hand we let me know

if there's any tenderness okay any tenderness okay any tenderness all right I don't feel any guarding and I doesn't feel any masses and I'm gonna go with

two hands I'll roll deeper let me know if there's any tenderness okay all right I didn't fill any guarding she said

there's no tenderness I didn't feel any masses and I didn't feel any enlarged organs you may cover yourself up now all right so the last thing we're gonna have

you do is come over to the side of the bed I'm just gonna check your spine if

you don't mind standing up all right so if you want to you can hold this over you and I'm just gonna lift the shirt a little bit the first thing I'm just gonna look as

you're standing straight I can kind of see but I'm going to raise this one shirt up okay I'm sorry and then I'm palpating when I palpate is

there any tenderness okay can you please bend over slightly I don't see any scoliosis slide lordosis or kyphosis all

right you can go ahead and sit down here on the bed do you have any questions for me no okay I think this concludes our head-to-toe physical exam thank you so

much I'm going to go clean my hands and I'm going to go document thank you you're welcome this concludes our final head-to-toe exam demonstration

you [Music]