Hi I Care

Hicare

Hand hygiene

do: Enter the room and visibly perform hand hygiene.

say:I'm performing hand hygiene

why: Reduces transmission of microorganisms and prevents infection.

Introduce yourself

do: Face the patient, smile, and make eye contact.

say to Patient:

“Hi, I'm Eva, I'll be your student nurse today.”

Provide privacy

do: Close the curtain or door.

say to Patient: I'm providing privacy now

why: Protects the patient's dignity and confidentiality.

Identify the patient

do: Look at the wristband while the patient answers. Compare both identifiers with the wristband.

"Can you tell me your name and date of birth?"

why: Two patient identifiers ensure you are assessing the correct patient.

Explain the plan

do: Face the patient and explain the assessment.

Say to Patient:

"Today I will be performing a physical assessment. I'll explain what I'm doing as I go. Please let me know if you experience any pain or discomfort at any time."

why: Promotes understanding, cooperation, and patient safety.

2. Review of Systems

Say to Patient:

“Before I begin, do you have any allergies? If so, what are they?”

why: Identifies substances that could cause an allergic reaction.

Say to Patient:

“Are you having any trouble breathing? If yes, can you describe it?”

why: Screens for respiratory distress or changes in oxygenation.

“When was your last bowel movement?”

why: Assesses gastrointestinal function and possible constipation.

“Have you fallen in the last six months? If so, when was the last time?”

why: Identifies fall risk and the need for safety interventions.

Say to Patient:

“Do you wear hearing aids, glasses or contacts, or dentures?”

why: Sensory aids may affect communication, safety, and assessment accuracy.

3. H.E.E.N.T — Head, Face & Scalp

Explain the section

say to Patient:

“I'm going to begin by assessing your head, face, scalp, and hair. I'll also gently feel your skull so if you feel any tenderness please let me know.”

Head and face

do: Inspect the head and face from the front and sides.

say Findings:

“Head is normocephalic. Facial structures are symmetrical. Skin is normal in color and tone for patient, intact, no lesions.”

why: Assesses head shape, facial symmetry, skin integrity, swelling, and lesions.

Scalp and hair

say to Patient:

“I'm going to part your hair in a few areas to inspect your scalp.”

do: Part the hair and inspect the scalp surface. Observe hair distribution and texture.

“Scalp is intact with no lesions or tenderness. Hair is evenly distributed with normal texture.”

why: Assesses for lesions, irritation, infection, tenderness, and abnormal hair distribution.

Skull palpation

Say to Patient:

“Now I'm going to gently feel your skull. Please let me know if you feel any tenderness.”

do: Palpate the entire skull with your fingertips.

Ask:

“Do you have any tenderness?”

say Findings:

"Skull is symmetrical and intact. No tenderness during palpation."

why: Detects tenderness, masses, depressions, or abnormalities that may not be visible.

4. H.E.E.N.T — Eyes: External Structures

“Now I'm going to assess your eyes. I'll be checking the structures around your eyes, your pupils, and your eye movements.”

Eyebrows

do: Inspect and compare both eyebrows.

“Eyebrows are symmetrical, normal in color and tone for patient, with full distribution.”

why: Assesses symmetry, skin changes, and abnormal hair loss.

Eyelids

Say to Patient:

“I'm going to inspect your eyelids.”

do: Inspect both eyelids for symmetry, drooping, swelling, and lesions.

Say Findings:

“Eyelids are symmetrical, normal in color and tone for patient, no ptosis or lesions.”

why: Assesses for ptosis, swelling, lesions, inflammation, or possible neurological abnormalities.

Conjunctiva

Say to Patient:

“Please look up for me while I gently pull down your lower eyelid.”

do: Gently pull down one lower eyelid and inspect. Repeat on the other eye.

“Conjunctivae are pink and moist bilaterally.”

why: Assesses circulation, hydration, irritation, and inflammation.

5. Eyes — Internal Structures & E.O.M

Eye position

Say to Patient:

“I'm going to look at the position and alignment of your eyes.”

do: Compare both eyes from the front.

Say Findings:

“Eyes are equal, round, and in normal position bilaterally.”

why: Assesses for abnormal alignment, protrusion, or asymmetry.

Sclera

Say to Patient:

“I'm inspecting the sclera or the white part of your eyes.”

do: Inspect both sclera.

Say Findings:

“Sclera are white bilaterally.”

why: Assesses for discoloration, irritation, or inflammation.

Iris

“I'm inspecting your irises now.”

do: Compare the shape and appearance of both irises.

“Irises are round, equal, and consistent with baseline bilaterally.”

why: Assesses equality and regularity of the irises.

perla

Accommodation must actually be tested.

Say to Patient:

“Now I'm going to check how your pupils respond to light and changes in focus. I'll shine my penlight from the side of each eye, is that okay.”

do: Inspect both pupils for equality and roundness.

Say to Patient:

“Please look straight ahead.”

do: Bring the penlight in from the side and observe pupillary constriction. Repeat on the other eye.

Accommodation

Say to Patient:

“Now please look at an object in the distance. Then, when I tell you, look at my finger.”

do: Hold your finger approximately 12 inches away.

“Now look at my finger.”

do: Observe the pupils constrict and the eyes converge.

“Pupils are equal, round, and reactive to light and accommodation — perla.”

why: Assesses neurological function and appropriate pupillary response to light and focusing changes.

Six cardinal fields of gaze

Say to Patient:

“Now I'm going to check your eye movements. Please keep your head still and follow my finger using only your eyes.”

do: Move your finger slowly through an H pattern. Observe for nystagmus or lag.

Image summary: An anatomical diagram of a human eye illustrating the muscles responsible for eye movement and the resulting directions of gaze. Arrows point outward from the center of the eye to indicate that the superior rectus causes elevation, the inferior rectus causes depression, the lateral rectus causes abduction, and the medial rectus causes adduction. Additionally, the inferior oblique is associated with upward movement and the superior oblique is associated with downward movement.

“Extraocular movements are intact in all six cardinal fields of gaze bilaterally.”

why: Assesses eye movement and cranial nerves 3, 4, and 6.

6. H.E.E.N.T — Ears

Explain the section

“Now I'm going to inspect your ears. I've also been assessing your hearing based on how you've responded throughout our conversation.”

Hearing

Say Findings:

“Client's hearing is intact as evidenced by appropriate responses throughout our conversation.”

why: Appropriate responses indicate the patient can hear and understand normal conversation.

Ear symmetry

do: Compare the position, size, and angle of both ears.

say Findings:

“Ears are symmetrical bilaterally.”

why: Assesses for abnormal positioning or asymmetry.

Auricle

Say to Patient:

“I'm going to inspect the outside of your ears.”

do: Inspect both external ears.

“Skin of the auricle is normal in color and tone for patient, intact, no lesions.”

why: Assesses skin integrity, lesions, and inflammation.

External auditory meatus

Say to Patient:

“I'm going to look at the opening of each ear canal.”

do: Inspect each visible ear canal opening.

say Findings:

“External auditory meatus is patent bilaterally, no visible discharge or obstruction.”

why: Assesses for drainage, obstruction, or visible foreign material.

7 & 8. H.E.E.N.T — Nose

Explain the section

say to Patient:

“Now I'm going to inspect the outside and inside of your nose.”

External nose

do: Inspect from the front and sides.

say Findings:

“Nose is midline and symmetrical.”

do: Inspect the external skin.

“Skin of the nose is normal in color and tone for patient, intact, no lesions.”

do: Inspect the nares for drainage.

“No external nasal discharge present.”

why: Assesses symmetry, skin integrity, and visible drainage.

Internal nose

Say to Patient:

“Please tilt your head back slightly. I'm going to use my penlight to look inside each nostril.”

do: Inspect one nostril and then the other with the penlight.

Say Findings:

“Nasal mucosa is pink and moist bilaterally.”

“No internal nasal discharge noted bilaterally.”

“No foreign bodies visualized in the nasal cavity bilaterally.”

why: Assesses mucosal health and checks for drainage or anything that could obstruct the airway.

9. H.E.E.N.T — Mouth & Oropharynx

“Now I'm going to inspect your mouth, including your lips, teeth, gums, tongue, and the inside of your cheeks.”

Lips

“I'm going to begin by looking at your lips.”

do: Inspect the lips.

Say Findings:

Lips are symmetrical, pink, moist, and intact.

why: Assesses hydration, circulation, and skin integrity.

Teeth and gums

Say to Patient:

"Please open your mouth for me. I'm going to inspect your teeth and gums."

do: Use the penlight to inspect.

Say Findings:

“all Teeth are present and intact.”

“Gums are pink, moist, and without lesions.”

why: Assesses oral health, dentition, inflammation, lesions, and hydration.

Tongue

Say to Patient:

“Please stick out your tongue for me.”

do: Inspect the top and sides and observe whether it remains midline.

"Tongue is midline, pink, moist, and intact. No lesions noted."

why: Assesses oral health, hydration, lesions, and tongue alignment.

Buccal mucosa

“I'm going to look inside both of your cheeks.”

do: Use the penlight to inspect bilaterally.

Say Findings:

“Buccal mucosa is pink, moist, and intact bilaterally. No lesions noted.”

why: Assesses for irritation, ulcers, lesions, infection, and hydration.

10. Neck

Explain the section

Say to Patient:

“Now I'm going to assess your neck, including the skin, the veins in your neck, and your carotid pulses.”

Inspection

do: Inspect the anterior and posterior neck.

“Neck is symmetrical. Skin is normal in color and tone for patient, intact, no lesions.”

why: Assesses symmetry, swelling, masses, and skin abnormalities.

Jugular veins

“I'm going to position you slightly upright and use my penlight to look at the veins in your neck.”

do: Position the patient at 30 to 45 degrees.

Say to Patient:

“Please turn your head slightly to the side.”

do: Use the penlight at an angle and inspect the opposite side. Repeat bilaterally.

Say Findings:

“No jugular venous distension present bilaterally.”

why: Assesses venous pressure. J.V.D may indicate fluid overload or impaired cardiac function.

Carotid pulses

Say to Patient:

“Now I'm going to gently feel the pulse on each side of your neck

do: Palpate one carotid at a time using your index and middle fingers.

Say Findings:

“Carotid pulse is regular in rhythm with amplitude of 2+ bilaterally.”

why: Assesses blood flow toward the brain. Never palpate both carotids simultaneously.

11. Upper Extremities

“Now I'm going to assess your arms and hands. I'll be checking your skin, nails, circulation, hydration, swelling, and pulses.”

Skin inspection

do: Inspect both arms, forearms, and hands.

Say Findings:

“Upper extremities are symmetrical bilaterally. Skin is normal in color and tone for patient, intact, no lesions or joint abnormalities.”

why: Assesses symmetry, skin integrity, swelling, and joint abnormalities.

Nails

Say to Patient:

“I'm going to inspect your fingernails.”

do: Inspect both hands.

Say Findings:

“Nails are clean. Nail beds are pink with normal contour. No clubbing bilaterally.”

why: Nail findings provide information about circulation and oxygenation.

Capillary refill

“I'm going to press on your nail beds to check for your capillary refill.”

do: Press, release, count, and assess bilaterally.

“Capillary refill is less than 2 seconds bilaterally.”

why: Assesses peripheral circulation and tissue perfusion.

Skin turgor

Say to Patient:

“I'm going to gently pinch your skin to check your hydration.”

do: Pinch the dorsum of the hand or forearm, release, and assess bilaterally.

Say Findings:

“Skin turgor is normal with no tenting bilaterally.”

why: Assesses hydration status.

Edema

Say to Patient:

“I'm going to gently press on your arms and hands to check for swelling.”

do: Palpate the forearms and dorsum of both hands.

Say Findings:

“No edema present in upper extremities bilaterally.”

why: Assesses for abnormal fluid accumulation.

Radial pulses

“I'm going to feel the pulses at your wrists and compare both sides.”

do: Use your index and middle fingers, not your thumbs. Palpate and compare bilaterally.

“Radial pulses are regular in rhythm with amplitude of 2+ bilaterally.”

why: Assesses peripheral circulation and compares blood flow bilaterally.

12. Chest — Respiratory

Explain the section

Say to Patient:

“Now I'm going to inspect your chest and listen to your lung sounds. I'll need to look at both the front and back of your chest.”

Chest inspection

do: Inspect the anterior chest.

Say to Patient:

“I'm inspecting the front of your chest for symmetry, skin condition, posture, and your effort of breathing.”

do: Have the patient lean forward and inspect the posterior chest.

Say to Patient:

“Please lean forward for me so I can inspect the back of your chest.”

“Skin is normal in color and tone for patient, intact, no lesions. Chest wall is symmetrical. Posture is upright. No increased effort with breathing.”

why: Assesses skin integrity, chest symmetry, posture, and respiratory effort.

Lung auscultation instructions

“I'm going to listen to your lungs now. Please take slow, deep breaths through your mouth each time you feel my stethoscope move.”

Anterior lungs

say to Patient:

“I'm going to begin by listening to the front of your chest.”

say:

“I am auscultating over the anterior thorax.”

do: Auscultate directly on the skin, comparing side to side, with at least two fields per side.

say Findings:

“Lung sounds are clear in the anterior fields bilaterally.”

why: Assesses air movement and abnormal breath sounds.

Posterior lungs

Say to Patient:

“Please lean forward for me. Now I'm going to listen to the back of your lungs.”

say:

“I am auscultating over the posterior thorax.”

do: Auscultate side to side, with at least two fields per side.

“Lung sounds are clear in the posterior fields bilaterally.”

why: Assesses a large portion of the lungs, particularly the lower lobes.

Lateral lungs

Say to Patient:

“Now I'm going to listen along the sides of your chest.”

say:

“I am auscultating over the lateral thorax.”

do: Auscultate the lateral/axillary fields bilaterally.

say Findings:

“Lung sounds are clear in the lateral fields bilaterally.”

why: Assesses the lateral lung fields and compares air movement bilaterally.

13. Chest — Heart

Explain the section

say to Patient:

“Now I'm going to listen to your heart sounds in five different areas. I'll be moving my stethoscope across your chest to listen to each valve area.”

Remember: A arrow P arrow E arrow T arrow M

Aortic “I'm starting at the aortic valve area.”

do: Place the stethoscope at the 2nd intercostal space, right sternal border.

do: Listen.

Say Findings:

S.1 and S.2 present and regular at the aortic valve.”

Pulmonic

Say to Patient:

“Now I'm moving to the pulmonic valve area.”

do: Move to the 2nd intercostal space, left sternal border.

do: Listen.

Say Findings:

S.1 and S.2 present and regular at the pulmonic valve.”

Erb's Point

Say to Patient:

“Now I'm moving to Erb's Point.”

do: Move to the 3rd intercostal space, left sternal border.

do: Listen.

S.1 and S.2 present and regular at Erb's Point.”

Tricuspid

“Now I'm moving to the tricuspid valve area.”

do: Move to the 4th intercostal space, left sternal border.

do: Listen.

Say Findings:

S.1 and S.2 present and regular at the tricuspid valve.”

Mitral

Say to Patient:

"Lastly, I'm moving to the mitral valve area."

do: Move to the 5th intercostal space at the midclavicular line.

Say Findings:

S.1 and S.2 present and regular at the mitral valve.”

why for Heart Section: Listening at all five areas allows you to assess S.1 and S.2 and identify irregular or abnormal heart sounds.

14. Lower Extremities

“Now I'm going to assess your legs and feet. I'll be checking your skin, toenails, circulation, hydration, swelling, and pulses.”

do: Inspect both legs, ankles, and feet.

“Lower extremities are symmetrical bilaterally. Skin is normal in color and tone for patient, intact, no lesions or joint abnormalities.”

why: Assesses symmetry, skin integrity, swelling, and joint abnormalities.

Toenails

Say to Patient:

“I'm going to inspect your toenails.”

do: Inspect bilaterally.

Say Findings:

“Toenails are clean. Nail beds are pink with normal contour. No clubbing bilaterally.”

why: Assesses circulation and oxygenation.

Capillary refill

Say to Patient:

“I'm going to press on your toenails to check how quickly the color returns.”

do: Press, release, count, and assess bilaterally.

“Capillary refill is less than 2 seconds bilaterally.”

why: Assesses peripheral circulation and tissue perfusion.

Skin turgor

“I'm going to gently pinch the skin on your lower legs to check your hydration.”

do: Pinch the lower-leg skin, release, and assess bilaterally.

Say Findings:

“Skin turgor is normal with no tenting bilaterally.”

why: Assesses hydration status.

Edema

Say to Patient:

“I'm going to gently press on your lower legs, ankles, and feet to check for swelling.”

do: Palpate the lower legs, ankles, and dorsum of both feet.

Say Findings:

“No edema present in lower extremities bilaterally.”

why: Assesses for abnormal fluid accumulation.

Dorsalis pedal pulses

Say to Patient:

“I'm going to feel the pulses on the tops of your feet and compare both sides.”

do: Use your index and middle fingers, not your thumbs. Palpate the dorsum of each foot and compare.

"Dorsalis pedal pulses are regular in rhythm with amplitude of 2+ bilaterally."

why: Assesses peripheral circulation and blood flow to the feet.

15. Closing

Say to Patient:

“That completes my physical assessment. Is there anything else I can do for you?”

do: Make sure the patient is comfortable and scan the room for safety hazards.

Say:

“I would document my findings at the bedside or the nurses' station.”

why: Documentation creates a legal record, communicates findings, and allows changes to be tracked.

Absolute final action

do: Visibly perform hand hygiene. Do not touch the patient or equipment afterward.

Say:

“I am performing hand hygiene before leaving.”

why: Prevents transmission of microorganisms after patient contact.

This version now has all four pieces incorporated in the actual order you'll use them: what you tell the patient to what you physically do to the exact finding you verbalize for points to why you're assessing it.

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