Health Assessment NURS 2820

Final Exam Demonstration –Head to Toe Clinical Assessment

Student Name:
Start Time: End Time:
Date:

Anything marked with an asterix only requires an explanation of how to do the assessment.
All other steps of the assessment must be demonstrated and explained.

Introduce self
Complete an environmental scan – O2/Oral airway/NP in pkg,
suction/functioning/connecting tube/yankeur, call bell within reach, bed /2
in lowest position and call bell within reach
Obtain consent for assessment
General Survey
 Level of consciousness, position, skin colour, facial expression,
presence of distress or pain /2
Subjective inquiry (0.5 each)
P
Q
R
S
T
U /3
**Identify vital signs have been assessed, report values obtained and
discuss findings and report normal ranges of each:
temp* Radial Pulse* Respirations* BP * 02 saturation** (0.5 each) /4
Assess orientation (0.5)
Check pupils (PERRLA) (0.5) /1
Inspect upper extremities
 Symmetry, skin colour & condition, edema /1
Palpate
 Temperature
 Pulses (Radial and Brachial)
 Muscle strength of upper extremities
 Capillary refill /4

Page 1 Total /17

Inspect anterior chest
 Shape & configuration (elliptical, ribs sloping downward,
symmetrical)
 Quality of respirations
 Anteroposterior diameter: transverse ratio =1:2 /3
Palpate
 Tenderness/masses /1
Auscultation
 Follows 5 point sequence comparing left to right, clear, good a/e
bilaterally, no adventitious breath sounds /1
Assess chest tube/suction/tracheostomy dressing/oxygen*
/1
Inspect
 Precordium (skin colour & condition) /1
Auscultate
 Appropriate landmarks(APETM sequence)with diaphragm /2.5
 apical rate* /1
 Asses with bell*/ left lateral position* /1
 Identifies where lub/dub loudest when assessing landmarks* (0.25 /1.5
each)
Inquires about changes in appetite and last BM, Nausea, Vomiting,
Diarrhea, Constipation* /1
Inspect
 Abdomen (contour, symmetry, scars, straie) /1
Auscultate
 Bowel sounds starting in RLQ and proceeds to RUQ, LUQ, LLQ /1
 Must listen for 5 second per quadrant /1
 Acknowledge it can take up to 5 minutes to determine absence of /1
bowel sounds
Palpation
 Light palpation (1 cm using fingertips) /1
 Identifies palpating painful region last * /1
 Would not palpate any pulsating mass* /1
Assess urine output/size of foley * (0.5) /0.5
assess dressings*/colostomy*/ileostomy*/bruits* (0.5)_ /0.5
Inspect lower extremities
 Symmetry, skin colour & condition, hair distribution, edema /1
Palpate
 Temperature
 Pulses (Dorsalis Pedis) /4
 Muscle strength in lower extremities
 Capillary refill
Assess dressing* /1
Page 2 Total /28
 Assist patient to sit at side of bed (or in high fowlers)

Assessment of posterior/lateral chest

Inspect
 Symmetry of posterior chest, skin colour & condition /1
 Alignment of spinous process
Palpate
 Tenderness*, masses* /1
Auscultation (posterior and lateral):
 General auscultation (follow 8 point sequence and 2-3 point for /2
lateral, clear, good a/e bilaterally, no adventitious breath sounds)
Assess dressing* /0.5
Discuss findings /plan, identifying collaborative goals for the day (discuss
discharge if appropriate) /0.5
Deduct one point if student does not follow correct order
Deduct two point if student demonstrates poor communication skills, lack
of professionalism and poor comportment
Deduct one point if student completes assessment components that are
inappropriate for the system being assessed. 1 mark per inapplicable
assessment.
Page 3 Total
/5
Page 2 Total
/28
Page 1 Total
/17

Final Mark Total

/50

Weighted mark /35

Revised April 2023