OSCE

VITAL SIGNS
Part 1. Patient’s Room
● SAFETY “I can see that the scene is safe to approach

● PRIVACY “ I’m closing the door for privacy”
● INTRO “Hello John, My name is ___________ one of the Registered Nurses here
who will be looking after you today. How are you doing?”
-simultaneously do hand hygiene
● ID “So John, I’m here to do your Vital Sign measurement but before doing that
is it okay if I’ll check your identification band please?”
“Can you confirm your Full name and DOB please, and your MRN
is____________”
● ALLERGY “By the way, do you have any allergies”
If yes - “I can see that it’s charted here and i’ll make sure that it will
not be given to you during your stay here”
● PAIN “Are you comfortable at the moment”
If in pain- quickly ask location, quality, meds taken, is it tolerable, offer relief
or comfort measures then ask permission to continue procedure
● EXPLAIN “Basically John, the procedure will involve me measuring your BP, PR, RR, Temp
and O2 Sat. The result will tell us how well your body’s vital organs are
functioning.``
● CONSENT “Are you okay with that”
● ASSESS Ask procedure specific questions:
“John, I’m just going to ask a few quick questions, would that be okay?”
“In the last 15 minutes did you smoke / had caffeinated drinks / taken any
kind of medicine / any vigorous physical activity”
“All looks good, I’ll just go gather my equipments and be back in

a moment but if you need anything feel free to use the buzzer to call me”
● HAND HYGIENE
Part 2. Treatment Room
● GATHER ÉQUIPEMENTS
■ BP App
■ Stethoscope
■ Thermometer
■ Pulse oximeter
■ State “All the equipments that I am going to use are clean, disinfected and
well-calibrated.”
BLOOD PRESSURE
● POSITION “John, is it okay if I position you sitting upright?”

“I’ll just place the pillow underneath your arm to make sure it is within the
level of your heart and if you could please uncross your legs for me too”
“Thank you”
● PREFERENCE “I will use this adult cuff which will cover 80% of your arm circumference”
“Which arm would you like me to take your Blood Pressure”
● CHECK SITE “I can see that you have no cannula or av fistula here (preferred arm)”
“Have you had any recent surgeries on the arm, axilla or shoulder”
● PERFORM “I am placing the cuff 2-3 cm above your Antecubital Fossa, let me
know if it’s too tight or too loose. You will also get a squeeze feeling while
I’m inflating the cuff ”
● Baseline BP “I will check now your baseline SBP by feeling your radial pulse while
inflating the cuff and only to STOP when I feel your pulse no more then
slowly releasing it at 2-3 mmHg/sec.
● Confirm BP “I will confirm now your Systolic BP by placing the diaphragm of my
stethoscope over your brachial pulse and adding 30 mmHg to the baseline
SBP and then releasing the cuff at 2-3 mmHg/sec to get the final BP reading”
“Looks good. I’m done checking your Blood Pressure now”
TEMPERATURE
● PREFERENCE “Which ear would you like me to take your Temperature”

● SITE CHECK “Have you not been lying on this side for more than 30 minutes?”
“I’ll just pull up and out to check for the presence of any drainage, cerumen
or any signs of inflammation and perforation”
“Looks nice and good to use”
.
● PERFORM Check the TEMPERATURE using TYMPANIC THERMOMETER.
“Looks good. I’m done checking your Temperature now”
O2 SATURATION
● PREFERENCE “Which hand would you like me to take your Oxygen Saturation”
● SITE CHECK “Checking for for fake nails or nail polish and and ensuring that the
finger is warm to touch and I can see that it looks nice and good to use”
● PERFORM Place the turned on pulse oximeter to pointing finger to get the
reading. While SP02 is reading, proceed to check on PR and RR.
PULSE RATE (PR) AND RESPIRATORY RATE
● POSITION Check the pulse rate by palpating on the radial pulse of the other
arm while placed across the chest/abdomen of the patient.
“Can please place your hand across your chest/abdomen for me please while
I check your pulse rate”
● PERFORM If the rate and rhythm is regular then only check PR for 30 seconds
then proceed to check the RR in the next 30 secs.
State “All good. I’m done checking your PR and HR in full minute
each”
● SEDATION “I can see that you are talking to me in full sentences so your sedation
PAIN score is 0 and mentioned that your pain score is ___ have no pain”
● H&H Perform quick hand hygiene while talking to patient

● RECAP Provide result of procedure performed
● H. TEACHING Provide teaching based on the situation.
● DOCUMENT Make documentation and sign as required
(Mention pain and sedation score)
● END “If you need anything feel free to use this buzzer to give me a call. Is
there anything else that I can help you with before I go”
IV PRIMING

● INTRO “Hello John, My name is ___________, one of the Registered Nurses here
● ID “So John, I’m here to give your IV Fluid as ordered by your Doctor but before
doing that is it okay if I check your identification band, please?”
“Can you confirm your Full name and DOB please, and your MRN is_________”
not be given to you during your stay”
● EXPLAIN “Basically John, your IV fluid was ordered for your indication and this will
help with desired effect”
● ASSESS Ask procedure specific questions & quick look at the site to use, if any:
“The cannula is within 72 hours from insertion, no visible signs of

inflammation such as redness, the VIP score is “0””
Ask the patient if the site is painful or tender
“All looks good, I’ll just go gather my equipements /

medication / articles and be back in a moment but if you need
anything feel free to use the call bell to give me a buzz okay”
● HAND HYGIENE
● ORDER VALID “The order is legible and valid, I am happy to proceed with my first
check”
● 1st CHECK Complete first check (5 Rights) Patient/Drug/Dose/Route/Time
Check IV fluid: “I can see that my IV fluid is correct, intack, no discoloration
or precipitate and within expiry date, so I’m happy to use”
● GATHER ARTICLES
■ Tray - “The tray is nice and clean and good to use”
■ IV drip set
■ Possy Flush 1 (Syringe, Drawing up needle, Water / NSS)
■ Alcohol swab 1
■ Gloves 1
State- “All my articles are nice, intact and within the expiry date
● 2nd CHECK Complete second check with 2nd Nurse

“Can you tell me you name and role, please”
“Are you happy to do the 2nd check with me” “Thank you”
● CALCULATE Proceed with IVF rate calculation and show to 2nd Nurse
● PREPARE Partially open the packaging of all articles
Quick hand hygiene
Prepare flush using ANTT -if not possy flush
Discard sharp in sharp bin
Put the flush back to the packaging
● PREPARE Prepare priming using ANTT
Open IV infusion set, put in the tray and close the IV regulator clamp.
Spike infusion set to IV fluid and hang to IV Pole
Squeeze fluid to the drip chamber until 3/4 full and then open the
regulator and allow the solution to flow the entire length ensuring no air
trapped in the IV administration set tubing before closing the clamp
“Label the IV set if available” state
Part 3. Back to Patient’s Room
● INTRO Perform hand hygiene, introduce the 2nd Nurse and the reason why she’s
there
● ID/3rd CHECK Complete ID check and third check with the 2nd Nurse, hang fluid
● POSITION Position patient appropriately and comfortably
● HH & GLOVES Quick hand hygiene and wear gloves
● DISINFECT Clean IV port with alcohol swab for 10 secs and letting it dry for 30 secs
● FLUSH Flush the IV cannula - to check patency
● CONNECT Connect the IV tubing to IV cannula using ANTT
● CONNECT Regulate the IV as prescribed

● DOCUMENT Document and sign the chart with 2nd Nurse
● END “I will check on you in 30 minutes. But if you feel anything unusual or need
need anything feel free to use this buzzer to give me a call. Is there anything
else that I can help you with before I go”
ANTT WOUND DRESSING

● ID “So John, I’m here to do your Wound Dressing but before doing that
Is it okay if I check your identification band, please?”
is____________”
● ALLERGY “By the way, do you have any allergies” - Latex, Adhesive, Tape
not be used / given to you during your stay”
● EXPLAIN “Basically John, the procedure that I’m going to do will involve wound care
and wound dressing change. This will help keep your wound clean to prevent
infection and will facilitate faster healing”
Ask if they need to use the bathroom prior to the procedure.

Perform a quick check on the dressing before leaving the patient’s
bedside. REMEMBER: Expose only what you need!
If without dressing -describe the wound (MEASURE)

● HAND HYGIENE
● GATHER EQUIPMENT / ARTICLES

■ Trolley - “The trolley has been cleaned within the last 24 hours”.
Disinfect the trolley from top to bottom.
[TOP: Farthest side to nearest, 1 stroke only]
then side rails and poles
[BOTTOM: farthest to nearest, 1 stroke only]
■ Dressing pack
■ Dressing
■ Bandage
■ Bluey
■ PNSS
■ Sanitizer
■ Gloves
■ Tape
■ Clinical waste bin
Put all articles in the bottom part of the trolley.
State-: “ All my articles nice, intact and within the expiry date”
● H&H Perform hand hygiene while greeting patient again

● GLOVES Wear gloves
● POSITION Confirm if the patient had finished using the toilet
Place patient to appropriate comfortable position and expose site
● Take the old dressing off and discard. Place bluey.
● H&H Quick hand hygiene
● PREPARE Open dressing pack and dressing, organize then nss
Prepare wet and dry gauze
● WOUND CARE Perform wound care. Ask patient regarding pain and comfort
before/during/after procedure
Depending on the SCENARIO insert: in-depth wound assessment/specimen
collection/wound irrigation -from CLEAN to INFECTED
“Are you comfortable at the moment?”
● ASSESS Assess wound using quick MEASURE
● WOUND DRESS Place dressing , label (date and initial) Assess pain again. Position back
patient. Discard all articles

● H TEACHING Provide teaching based on the situation.
Inform the patient of the condition of the wound and the next wound
dressing date!
BT REACTION

● INTRO Quickly introduce yourself while doing hand hygiene “How are you doing?”
● Stop “You seem to be having a transfusion reaction. Let me stop the

Blood Transfusion”
If patient is experiencing DOB od SOB, position upright
● Check VS Immediately ask examiner for the vital sign

Yellow zone - no need to connect to O2 - RN/RM Review
Red zone - connect O2 at 2 lpm via nasal prong - MDT Review
Manage symptoms, provide comfort and reassure patient
Reassess patient -ask the examiner for latest vital sign

If stable, proceed to clerical checks
● Maintain IV “I have stopped the transfusion but left IV intact so we will have access,
don’t flush but I will no longer flush the line”
● Clerical Check “Your vital signs are now stable, but don’t worry I’ll stay with you but
meantime, is it okay for me to do the clerical checks while we are waiting for
the team just to make sure that we got everything correctly.
Check Patient ID band to Order chart -Name, DOB, MRN, Allergies
Order chart to blood Pack -Name, DOB, MRN, Blood product, ABO,
Donor or Lot number
Pack to Patient ID band --Name, DOB, MRN, ask pt blood type again
Explain if checks are correct
● Notify “I’ll make sure that the healthcare team and the blood transfusion provider
Blood Svc will be notified of this incident. I will send the blood pack for further
investigation to determine the possible cause of reaction”
● Collect sample “We may need to collect your urine and blood samples. So if you feel like
going to the toilet please let me know so I could give you the urine cup for
the specimen. I also make sure to send here one of our phlebotomists to
extract blood sample from you”
● Document “I’ll just do my documentation here in the room. I'll make sure that
that I’ll make an incident report regarding your blood transfusion
reaction“
Progress notes (bulleted) with patient demographics on top
CPR “DRS ABCD”
● Danger Check for any DANGER, the scene is safe to approach
● Response Tap shoulder “Hey John, can you hear me? If no response proceed to
“Can you please squeeze my hand”. If there is no response, illicit pain
at Trapezius squeezes if there is still no response. STATE “THE
PATIENT IS NOT RESPONDING!”
● Send for help! “Activating Emergency Response of Code Blue”.
● Airway “Checking AIRWAY using either Head-Tilt-Chin-Lift maneuver (no

spine injury) or Jaw Thrust (suspected spine injury). Remove pillow
State “AIRWAY IS PATENT AND CLEAR”
● Breathing “Checking BREATHING”

“Looking for rise and fall of chest, listening and feeling for
breath sound from mouth and nose. NO SIGN OF BREATHING”
● CPR “Activating bed CPR mode”

“STARTING CPR, by place my palm interlaced over the Lower Half of
the Sternum at a ratio of 30 compression for every 2 rescue breath
At a rate of 100-120 compression per minute with 1/3 depth of the
Chest while allowing Full Chest Recoil between compressions.
CONTINUE CPR UNTIL HELP ARRIVES
● Defibrillator
RN TAKING OVER SCENARIO and YOU WOULD BE DOING THE REST

● Who are you? Are you here to help? What is your role?
● “I AM A **** and I will help by taking over the chest compression”
● Optional: Can you please get the AED in the nearest station (If AED is not brought
over)
● If the AED is available, allow the second person to continue chest compression.
● Connect the PADS just below the Right Clavicle and the other pads to below the Left
Breast.
● Ensure to attach the PADS on a DRY CHEST and DO NOT PLACE over other OBJECT
(e.g Pacemaker, Jewelry, clothes).
● Turn on the AED and follow the prompts. Follow AED prompts.
● Prepare for VENTILATION, connect the Non-rebreathing mask to the oxygen outlet
at 10-15 LPM.
● Perform ventilation by Placing the tip of the mask on the bridge of the nose and seal
the nose and month with Caring C and pulling up chin with Caring E”
● Provide ventilation enough to see the Rise and Fall of the Chest with 1 Rescue breath
per sec.
● NOTE: When shock is advised: I AM CLEAR, YOU CLEAR, OXYGEN CLEAR (Turn off
oxygen) EVERYBODY CLEAR. Deliver shock.
● Continue to follow AED prompts or until Resus Team arrives to take over/ when there
is sign of life/declared dead by doctor/ impossible to to deliver quality chest
compression.
● Do ISBAR Handover
○ I Nurse/patient demographics
“My name is ________one of the Registered Nurse here at the Medical
Ward and this is Mr John Smith”
○ S Situation/time (what time found unresponsive)
“During my rounds at 7:15 AM I John on his bed to be unresponsive”
○ B Hx/allergies/meds
“John is a 72 years old who was admitted two days ago for
exacerbation of COPD”
○ A Airway, breathing- NO RESPONSE
“On assessment, I found his airway to be patent and clear but
not breathing and have no response”
○ R “I called for help and commenced CPR at around 7:16 AM. I already
given a total of 8 cycles of compression at a rate of 100 - 120
compression per minute and 6 ventilations provided. AED has been
attached and two shocks have been delivered but still John is not
breathing.”
“What would you like me to do, do you like me to continue CPR
or would you like to take over?”
“Thank you, I’ll be just right here if you need anything, I’ll just make
my documentation, make incident report and make way to inform the
family”
AIN OR PATIENTS WATCHER WOULD WANT TO HELP, YOU WILL CONTINUE CPR WHILE
INSTRUCTING THE OTHER PERSON
● Who are you? Are you here to help? What is your role?
● “I AM A **** and I want to help”
● Can you please get the AED in the nearest station (If AED is not brought over)
● Instruct the second person to connect the pads on the RIGHT CLAVICLE and the
other pads to BELOW THE LEFT BREAST.
● Ensure to attach the PADS on a DRY CHEST and DO NOT PLACE over other OBJECT
(e.g Pacemaker, Jewelry, clothes).
● Turn on the AED (DEFIBRILLATOR) and follow the prompts.
● Instruct the second person to grab the NON-REBREATHER MASK and hook the tube
to the oxygen source and turn on to 15 LPM.
● Allow the reservoir bag to fill with oxygen for 1-2 seconds.
● Provide ventilation by PLACING THE TIP OF THE MASK ON THE BRIDGE OF THE
NOSE. SEAL THE MOUTH AND NOSE WITH A CARING SEAL “C” and LIFT THE CHIN.
● Provide ventilation enough to see the RISE AND FALL of the CHEST giving 1 Rescue
breath per second when the AED prompts you to give BREATHS.
● Continue to follow AED prompts or until Resus Team arrives to take over/ when there
is sign of life/declared dead by doctor/ impossible to to deliver quality chest
compression.
● Do ISBAR Handover.
PAIN (Non-Pharmacological)

● ID “So John, I’m here to do your Pain Assessment but before doing that
Is it okay if I check your identification band, please?”
is____________”
or comfort measures first, assess, then ask permission to continue procedure
● EXPLAIN “Basically John, the procedure will determine your level of pain right now. The
result will help us guide in ways to address and alleviate your pain.”
“John, I’m sorry to see you in this situation, you must be in a lot of pain.
What happened?
“Have you taken any pain medication?”
P- Tell me what provokes the pain, what makes it worse or better?

Q- Can you describe the pain, is it a dull, stubbing, throbbing pain?
R- Where exactly is your pain, it is radiating?
S- Scale 0 - 10?
T- Does it stay all the time or does it go?
● Management Talk and provide all non-pharmacological intervention to address

the kind of pain “let me see what i can do to help with your pain”
● Comfortable position (put pillow under affected area)
● Sling application
● Bandage application
● Ice pack (wrap it with cloth, apply 15 minutes at a time, rotate)
● Diversional techniques
● REASSESS “How does that feel now, how is your pain”

“Now John, remember the scale that you gave earlier, if you're going
to rate your pain now, what would it be?”

● H TEACHING Provide teaching based on the situation.
“John, try to wiggle your finger to promote circulation. If there’s unusual
sensation like pins and needles or numbness or if you see that the finger
nails are turning blue, please let me know”
ORAL/BUCCAL/SUBLINGUAL MEDICATION

● ID “So John, I’m here to give your Oral Medication as ordered by your Doctor
which is due now but before doing that is it okay if I check your
identification band, please?”
is____________”
● EXPLAIN “Basically John, your Oral Medication was ordered for your indication and
this will help with desired effect”
● “Have you taken this medication before?”

● “Have you had any reaction to the medication?’
● “Do you have any swallowing difficulties?”

● HAND HYGIENE
check”
Check Oral Medication: “I can see that my medication is correct, intack, no
discoloration and within expiry date, so I’m happy to use”
● MIMS Check the Preparation and Administration Instructions
● GATHER ARTICLES
■ Medication cup
■ Water
■ Optional (pill cutter/crusher)
■ Gloves 1
State- “All my articles are nice, intact and within the expiry date”
● 2nd CHECK Complete second check / with 2nd Nurse (APINCH/Padia Patient)
● CALCULATE Proceed with the calculation / show to 2nd Nurse
● H&H Perform quick hand hygiene
● PREPARE When dispensing medication “It is nice and intact and no discoloration”
● INTRO Perform hand hygiene / introduce the 2nd Nurse and the reason why she’s
there (APINCH/Padia Patient)
● ID/3rd CHECK Complete ID check and third check / with the 2nd Nurse,
● POSITION Ask patient if they are comfortable or you could ask the patient to sit
up/raise the bed waist level.
● ADMINISTER Give medication and offer water.
● CHECK Ensure it is swallowed by asking the patient to open mouth

● DOCUMENT Document and sign the chart with 2nd Nurse (APINCH/Padia Patient)
SUBCUTANEOUS INJECTION

● ID “So John, I’m here to give your Subcutaneous Injection as ordered by your
Doctor which is due now but before doing that is it okay if I check your
is____________”
● EXPLAIN “Basically John, your Subcutaneous Injection was ordered for your indication
and this will help with desired effect”
● “When was the last time it was given to you?”

● “Where was the last site of injection?
● Preferred site? [ARMS, ABDOMEN, THIGHS AND BUTTOCKS]
● [If heparin: LOWER ABDOMINAL FAT PAD, JUST BELOW THE
UMBILICUS]
● Take a quick look at the preferred site if it’s good to use

● HAND HYGIENE
check”
CheckSubcut Medication: “I can see that my medication is correct, intack, no
discoloration or precipitate and within expiry date, so I’m happy to use”
● YELLOW BOOK Check the Preparation and Administration Instructions
● GATHER ARTICLES
■ Syringe
■ Drawing Up Needle
■ Injection Needle
■ Alcohol swab
■ Gloves
■ Sharp bin
● 2nd CHECK Complete second check / with 2nd Nurse

● CALCULATE Proceed with the calculation / show to 2nd Nurse
● H&H Perform quick hand hygiene
● PREPARE Prepare medication using ANTT
there
● POSITION Depending on the preferred site and expose only what is needed
Optional: clean injection site with alcohol swab for 10 secs and letting
it dry for 30 secs
● ADMINISTER “It will be a little bit uncomfortable but I will try my best to do it gently
as I can, please let know when it hurts”
Inject the medication opposite to the last injection site [rotate the
injection site]
If you could pinch at least 2 inches of the skin then inject the
medication at a 90 degree angle. [HEPARIN IS ALWAYS GIVEN AT 90
DEGREE ANGLE]
If you could pinch less than 2 inches of the skin then inject the
medication at a 45 degree angle.
Leave the needle in place for 10 seconds after injection then
withdraw and discard syringe and needle to the sharp bin
Cover site with gauze pad and apply gentle pressure
“Please don’t rub or massage the site after injection - may cause
hemorrhages or bruising”
If the patient bruises easily, apply ice to the site for the first 5
Minutes.

INTRAMUSCULAR INJECTION

● ID “So John, I’m here to give your IM Injection as ordered by your
is____________”
● EXPLAIN “Basically John, your IM Injection was ordered for your indication and this
will help with desired effect”

● “Have you had any reaction to the medication?”
● “Where was the last site of injection?
● “Any preferred site?
○ Detaid 1 ml
○ Ventrogluteal 2.5 ml
○ Vastus lateralis 5 ml
○ Rectus femoris 5 ml
○ Dorsogluteal 4 ml, not recommended
● Take a quick look at the preferred site if it’s good to use

● HAND HYGIENE
check”
CheckIM Medication: “I can see that my medication is correct, intack, no
● GATHER ARTICLES
■ Syringe
■ Drawing Up Needle
■ Injection Needle
■ Alcohol swab
■ Gauze
■ Gloves
■ Sharp bin

● CALCULATE Proceed with drug calculation and show to 2nd Nurse
● PREPARE [If vial - open and then disinfect, then allow 30 secs to dry, if ampule
leave it be] and other equipment by partially opening the sleeves of
the syringes and needles.
Perform quick hand hygiene and wear gloves
Prepare medication using ANTT
Remove gloves and perform hand hygiene
Back to Patient’s Room
there
● ADMINISTER “It will be a little bit uncomfortable but I will try my best to do it gently
Inject the needleUsing the Z-TRACK method at a 90 degree angle.
Optional: Aspiration before pushing medication
Leave it for 10 seconds before retracting.
Discard syringe and needle at sharp bin
Cover site with gauze pad and apply gentle pressure, inspect site for
active bleeding.
Apply an adhesive bandage as needed.
“Please don’t rub or massage the site after injection - may cause
hemorrhages or bruising”
If the patient bruises easily, apply ice to the site for the first 5
Minutes.

IV BOLUS ADMINISTRATION

● ID “So John, I’m here to give your IV Medication Injection as ordered by your
● EXPLAIN “Basically John, your IV Medication was ordered for your indication and this
will help with desired effect”

● “Have you had any reaction to the medication?”
● Take a visual inspection of cannula site for VIP score

“The cannula is within 72 hours from insertion, no visible signs of
inflammation such as redness, the VIP score is “0””
Ask the patient if the site is painful or tender

● HAND HYGIENE
check”
CheckIV Medication: “I can see that my medication is correct, intack, no
● GATHER ARTICLES
■ Syringe
■ Drawing Up Needles
■ Diluent (Vial)
■ Possy Flush 2 / 10 ml syringe 2, drawing up needle 2, 20 ml nss
■ Alcohol swab 2
■ Gloves 2
■ Sharp bin
■ State- “All my articles are nice, intact and within the expiry date”

● CALCULATE Proceed with drug calculation and show to 2nd Nurse
● PREPARE Open and then disinfect vial then allow 30 secs to dry, if ampule
leave it be and
Open partially opening the sleeves of other article
Perform quick hand hygiene and wear gloves
Prepare flush and medication using ANTT
Remove gloves and perform hand hygiene
there
● ADMINISTER Clean IV port with alcohol swab for 10 secs and letting
it dry for 30 secs
“It may be a little bit uncomfortable but I will try my best to do it gently
Flush IV cannula to check patency
Puch Medication (state to how long is the recommended time)
Flush IV cannula to ensure complete absorption of medication to circulation
Ask how the patient is doing while administering the medication.

BGL PROCEDURE

● ID “So John, I’m here to do your Blood Glucose Level measurement but before
“Can you confirm your Full name and DOB please, and your MRN is________”
● EXPLAIN “Basically John, the procedure will measure the level of glucose in your body.
and the result will tell us how well your body is absorbing your glucose and
this will help us in ways to manage and improve your health”
● “When did you have your last meal?”

● “Are you about to eat?”
● Ask patient to wash hand
“All looks good, I’ll just go gather my articles and be back in a moment but if
you need anything feel free to use the call bell to give me a buzz okay”
● HAND HYGIENE
● GATHER EQUIPMENT / ARTICLES

■ Glucometer - “My Glucometer is well calibrated and ready for use”
■ Strips - “The glucose strip is within expiry and matches with the glucometer”
■ Lancet
■ Gauze
■ Bluey
■ Alcohol swab (optional)
■ Gloves
■ Sharp bin
● INTRO Perform hand hygiene

● POSITION Confirm if the patient had finished washing their hands
Ask patient if they are comfortable or you could ask the patient to sit
up/raise the bed waist level.
“Which finger would you like me to take your BGL?”
Take a quick look at the preferred finger if it’s good to use
● PERFORM Proceed with the procedure
Give guazed to stop bleeding.
Discard sharps to a sharp bin.

● H. TEACHING Provide teaching based on the situation
NEUROLOGICAL ASSESSMENT

who will be looking after you today. Simultaneously do hand hygiene
How are you doing?” Start assessing GCS (EVM) here
● ID “So John, I’m here to do your Neurological Assessment but before
● EXPLAIN “Basically John, the procedure will measure the neurological functioning of
your body and the result will help us in ways to manage and improve your
health”
● Statutory “As part of the assessment I maybe touching areas of your body being
Declaration 2 assessed but in at any point during the assessment if you feel
uncomfortable, please let me know”

● PERFORM Ask procedure specific questions
● Orientation To Time, Place and Person
● Pronation Ask the patient to close eyes and lift your arms with the palms facing
Drifting the ceiling and hold it for 10 sec then iInstruct patient to open eyes
and you can put down your arms
● Arm Ask the patient to do chicken wings then ask the patient to resist
Strength whenever you would pushing away /pulling back his arm
Then ask the patient to do a hand boxing scene / bull barthen ask
the patient to resist whenever you would pushing away /pulling back
his arm
● Hip Ensure the client is lying on the bed.

Flexion Ask the patient to raise legs towards the ceiling (ensure not the knee
is not bent) apply pressure and ask the patient to resist and vice
versa
● Knee Ask the patient to bend knee and ask them to extend their legs
Flexion & towards the examiner while applying pressure and ask them to resist.
Extension Ask the patient to bend knee and bring their heel toward their
bottom while applying pressure and asking them to resist
● Dorsiflexion Ask the patient to bring their toes towards their head while applying
Plantarflexion pressure and ask them to resist.
Ask the patient to bring their toes towards the end of the bed while
applying pressure and asking them to resist.
● Pupillary Perform hand hygiene
Reaction Look for PERRLA
Inform the patient of the next step and they might be a little
uncomfortable
Instruct the patient to look straight and try not to blink.
Let the patient know that you will be directing a small bright torch from the
outer aspect of their eye towards the pupil.
Check for Pupillary Reaction on both eyes.
Then proceed to check on accommodation
Ask the patient to look at the tip of the penlight and move it towards them
while checking for the pupils to constrict.
Assess for cranial nerve if you still have time

● END “Thank you for your cooperationI I will check on you later. But need anything
Feel free to use this buzzer to give me a call. Is there anything else that I can
help you with before I go”
NEUROVASCULAR ASSESSMENT

● ID “So John, I’m here to do your Neurovascular Assessment but before
“Can you confirm your Full name and DOB please, and your MRN is________”
● EXPLAIN “Basically John, the procedure will measure the vascular and nerve
functioning of your affected limb and the result will help us in ways to
to manage and improve your condition or prevent possible complications”
Declaration 2 assessed but at any point during the assessment if you feel uncomfortable,
please let me know”
“Do you want to use the toilet before we start the examination?”
Ensure that nail polish, dirt, blood or any stained skin preparation is
removed from the distal extremities
Any jewelry is removed from the injured or affected limb

● PERFORM 6Ps
1. PAIN Ask PAIN. Is there unusual pain in your affected limb?

if pain is present perform QUICK PQRST assessment
Depending on the pain score, recommend non-pharmacological and
pharmacological pain management to address the pain.
2. PALLOR Visual inspection for color (PALLOR), blood, drainage, swelling,
3. PYLOCOTHERMIA Perform the examination by checking for the Temperature of the

affected limb
4. PULSE Check presence of PULSE -strong/weak/absent

● Radial
● Posterior tibialis
● Dorsalis pedis
Then fingertips/toes and check for capillary refill
5. PARESTHESIA Instruct the patient to close their eyes and inform them that you will
be stroking the back of their hands and for them to tell you when
they feel any tingling or prickling numbness sensation.
Record nerve sensation as Normal / Pins and Needles / Absent
6. PARALYSIS Assess for Movement (RUM / Peroneal Nerve / Tibial Nerve)

FALLS RISK ASSESSMENT FORM

● ID “So John, I’m here to do your Fall Risk Assessment but before
“Can you confirm your Full name and DOB please, and your MRN is__________”
● EXPLAIN “Basically John, the procedure will measure your level of risk of having falls
and the result will help us in ways to to manage and improve your condition
and put measures to prevent possible incidents to keep you safe throughout
your stay here””
● Statutory “As part of the assessment I will be asking questions and taking
Declaration 1 some notes”
1. John, do you remember if you had any fall within the last 3 months. How
about during your stay here? If any - how many
2. Are you taking any medication that makes you feel drowsy / sleepy /
antidepressant / void frequently / hypertension
3. Do you feel anxious now after the fall incident? Are you not able to do
the things that you used to do before because of fear of falling again?
How about your confidence? Do you think you can walk again with
confidence as before? How do you plan on gaining your confidence to
walk again?
4. Are you able to see clearly? If with glasses - when was the last time you
had your eyesight checked?
5. Are you using any mobility aids / do you need assistance when moving?
6. Do you know where you are right now? Do you know the date today?
What season are we in right now?
7. Unsafe footwear / inappropriate clothing / unsafe use of equipment
8. Difficulty orientation with the environment. Area between the bed,
bathroom, dining area
9. Did you have any changes with your appetite?
10. Do you have full control over your bowel and bladder?
11. If you have time, do some check to patient’s lower extremities

● DOCUMENT Document and sign as needed
URINALYSIS

● ID “So John, I’m here to do your Urinalysis but before doing that is it okay if I
check your identification band, please?”
If yes - “I can see that it’s charted here and I’ll make sure that it will
● EXPLAIN “Basically John, the procedure will measure presence and level og
components of your urine specimen and the result will help determine few
underlying condition like UTI, DM, others and also help us in ways to
manage and improve your health and prevent possible other conditions”

Check urine cup details with identifier “I have the urine cup here, I’ll just
make sure I have the correct details on the cup before you collect a sample”
Give the urine cup. “Before you collect please wash your private area first.
Then collect midstream urine by letting the first flow out then catch the
following urine on the midstream until cup is half full”
Put tissue paper/bluey on the table.
Let the client put the urine cup on top of it and slightly open the lid
Wear gloves and get a urine stick. Check expiry.
Dip the urine stick to the urine sample then tap the strip to the cup to
remove excess specimen on the strip
Start analyzing the result by holding the strip across the urine bottle. DO
NOT LET THEM TOUCH

Explain the result to the patient
If anything abnormal, say that you are going to the Doctor for further
management
● H TEACHING Provide health teaching based on the condition
Drink plenty of water to make the urine concentrated
Don’t hold urine
Don’t use scented wipes, better use soap and water
Wipe front to back to prevent bacterial infection
● DOCUMENT Document and sign as required
ABDOMINAL ASSESSMENT

● ID “So John, I’m here to do your Abdominal Assessment but before
is____________”
● EXPLAIN “Basically John, the procedure will assess the health functioning of you
abdominal organ and the result will help us determine underlying conditions
if there's any and will help us ways to manage and improve your health and
prevent possible other complications”
Declaration 2 assessed but in at any point during the assessment if you feel
“I’m just going to ask a series of questions, would that be okay?”
A - abdominal pain, appetite

B - bowel change
W - weight changes, is it intentional
I - indigestion
N - nausea and vomiting
D - diarrhea
M - menstruation if female
● GATHER EQUIPMENT
■ Stethoscope : “This has been cleaned and disinfected within the last 24 hours

● PERFORM IAPP
Inspection “I’m going to expose your abdomen.

Contour - flat / scaphoid / distended, stoma, tubes, drainage, wounds,
surgical incisions, discoloration, hernia
Auscultation “I’m going to listen to your abdominal regions as well as your
your abdominal, renal, and iliac arteries. Listen to bruit or bowel sound.
Normal 5-40
Percussion Percuss all 4 regions
Palpation. Do light and deep palpation. Look for rebound tenderness, massessm bumps, lumps.

Abnormal Signs
● Cullen sign - bluish on umbilical area
● Grey Turner’s sign - bluish on flank; retroperitoneal hemorrhage
● Kehr’s sign - pain on left shoulder, splenic injury, ectopic preg or ruptures AP
● Ballance’s sign - dull sound on LUQ upon percussion, splenic injury
● Murphy’s sign - cholecystitis
● Rovsing’s sign - rebound tenderness for AP
● Mcburney’s point - pain in RLQ for AP

RESPIRATORY ASSESSMENT

● INTRO “Hello John, My name is ___________t, one of the Registered Nurses here
● ID “So John, I’m here to do your Respiratory Assessment but before
is____________”
● EXPLAIN “Basically John, the procedure will assess the health functioning of you
lung and the result will help us determine underlying conditions if there's any
and will help us ways to manage and improve your health and prevent
possible other complications”
● Statutory “As part of the assessment I maybe exposing and touching areas of your
Declaration 2 body being assessed but I will make sure privacy is provided at all times and
at any point during the assessment if you feel uncomfortable, please let me
know”
“I’m just going to ask a series of questions, would that be okay?”
● Do you smoke
● What do you do for living
● Are you exposed to any inhalant ot chemicals
● Do you have any respiratory conditions or symptoms at the moment
● GATHER EQUIPMENT
■ Stethoscope : “This has been cleaned and disinfected within the last 24 hours

● PERFORM IPPA
Inspection I’m just going to expose your chest first. I’ll make sure privacy in provided, if
you feel uncomfortable, please let me know and I’ll stop
Note for: nasal flaring, circumoral cyanosis, symmetrical chest expansion,
chest tube and drainage, wounds and surgical incisions
Palpate Im going to palpate your chest now. It will involve me touching you, if you feel
uncomfortable, please let me know
Check for nodules, tracheal deviation, palpate chest for any masses, bumps,
lumps, subcutaneous emphysema, crepitus, popping sound
Check for chest symmetry
Percussion Percuss the lung fields, Resonating, dull, flat
Auscu;latate Listen for any abnormal breath sounds

Abnormal Signs
● Cullen sign - bluish on umbilical area
● Grey Turner’s sign - bluish on flank; retroperitoneal hemorrhage
● Murphy’s sign - cholecystitis
● Ballance’s sign - dull sound on LUQ upon percussion, splenic injury
● Kehr’s sign - pain on left shoulder, splenic injury, ectopic preg or ruptures AP
● Rovsing’s sign - rebound tenderness for AP
● Mcburney’s point - pain in RLQ for AP

PRESSURE INJURY ASSESSMENT

● ID “So John, I’m here to do your Pressure Injury Risk Assessment but before
“Can you confirm your Full name and DOB please, and your MRN is__________”
● EXPLAIN “Basically John, the procedure will measure your level of risk of potential
developing pressure injury and the result will help us in ways to manage and
improve your condition and put measures to prevent possible development
of pressure injury throughout your stay here””
● Statutory “As part of the assessment I will be asking questions and taking
Declaration 1 some notes”
● Do you have any idea what your BMI is / Can you tell me your height and
weight
● Are you current smoker
● Have you been diagnosed with conditions that might restrict your mobility
○ Spinal cord injury
○ Neurological condition
○ DM
○ Anemia / low blood count
○ Peripheral VSD
○ Rheumatoid arthritis
○ Osteoporosis
● Are you suffering from any organ failure / immunocompromised
● Are you taking medications for chemo / radiotherapy
● Do you have control over your bladder and bowel / how often do you change
your linen
● Are you able to finish your full meal
SKIN HISTORY
● Do you have any history of pressure injury / when?
● Do you suffer from any skin condition like eczema, dermatitis or psoriasis
● Are you sensitive to any skin products like perfumes, soap, dressings or
adhesive
BRADEN SCALE
● Sensory Are you able to respond to any pressure discomfort
● Mobility Are you able to change position on bed / chair alone
● Activity Are you able to transfer yourself or get yourself out of bed
chair alone
● Moisture
● Friction Do you need assistance when moving
● Nutrition How much food can you eat in full meal plate
SKIN ASSESSMENT
● Statutory Declaration 2 - “As part of the assessment I maybe exposing and
touching areas of your body being assessed but I will make sure privacy is
provided at all times and at any point during the assessment if you feel
● I’m going to inspect your skin, is it okay if you expose your back. I’ll make sure
to provide you with privacy while doing the assessment
● I will check for any warning signs like blanching, erythema, induration,
blisters and localized pain around your skin
● Check the bony prominence using inspection and palpation BEST SHOT
● Position back and client comfortable

● “Based on your Braden Scale, your score is _____ which is a ___________risk”
● “We will provide you with interventions to prevent the pressure injury from
developing”
MANAGEMENT
● High / Moderate Risk
○ Provide air mattress and chair cushion - offload the pressure from
affected areas
○ Change position every 1-2 hours (high risk), 2-4 hours (moderate risk)
○ Commence wound chart and management to include MR95a Form
○ Reassess Braden Scale , Pain Scale and Skin Inspection every shift
○ Inform medical officer, refer to dietician for high protein diet (high risk)
○ Refer to MDT (moderate risk)
○ Make sure there are no creases on bed
○ Apply barrier creams
○ Apply zinc cream when there’s redness
● Low Risk
○ Provide penflex and air mattress - offload the pressure from affected
areas
○ Repeat assessment weekly of if there’s any changes on skin,
neurological status and prior to discharge


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VITAL SIGNS

Part 1. Patient’s Room

● SAFETY “I can see that the scene is safe to approach

“All looks good, I’ll just go gather my equipments and be back in

Part 2. Treatment Room

● POSITION “John, is it okay if I position you sitting upright?”

“Looks good. I’m done checking your Blood Pressure now”

● PREFERENCE “Which ear would you like me to take your Temperature”

“Looks good. I’m done checking your Temperature now”

PULSE RATE (PR) AND RESPIRATORY RATE

● H&H Perform quick hand hygiene while talking to patient

Part 1. Patient’s Room

● SAFETY “I can see that the scene is safe to approach

“The cannula is within 72 hours from insertion, no visible signs of

“All looks good, I’ll just go gather my equipements /

Part 2. Treatment Room

● 2nd CHECK Complete second check with 2nd Nurse

Part 3. Back to Patient’s Room

● H&H Perform quick hand hygiene while talking to patient

Part 1. Patient’s Room

● SAFETY “I can see that the scene is safe to approach

Ask if they need to use the bathroom prior to the procedure.

“All looks good, I’ll just go gather my equipements /

Part 2. Treatment Room

● GATHER EQUIPMENT / ARTICLES

● H&H Perform hand hygiene while greeting patient again

● H&H Perform quick hand hygiene while talking to patient

● SAFETY “I can see that the scene is safe to approach

● Stop “You seem to be having a transfusion reaction. Let me stop the

● Check VS Immediately ask examiner for the vital sign

Manage symptoms, provide comfort and reassure patient

Reassess patient -ask the examiner for latest vital sign

● Danger Check for any DANGER, the scene is safe to approach

● Send for help! “Activating Emergency Response of Code Blue”.

● Airway “Checking AIRWAY using either Head-Tilt-Chin-Lift maneuver (no

● Breathing “Checking BREATHING”

● CPR “Activating bed CPR mode”

CONTINUE CPR UNTIL HELP ARRIVES

RN TAKING OVER SCENARIO and YOU WOULD BE DOING THE REST

Part 1. Patient’s Room

● SAFETY “I can see that the scene is safe to approach

P- Tell me what provokes the pain, what makes it worse or better?

● Management Talk and provide all non-pharmacological intervention to address

● REASSESS “How does that feel now, how is your pain”

● H&H Perform quick hand hygiene while talking to patient

Part 1. Patient’s Room

● SAFETY “I can see that the scene is safe to approach

● “Have you taken this medication before?”

“All looks good, I’ll just go gather my equipements /

Part 2. Treatment Room

Part 3. Back to Patient’s Room

● H&H Perform quick hand hygiene while talking to patient

Part 1. Patient’s Room

● SAFETY “I can see that the scene is safe to approach

● “When was the last time it was given to you?”

“All looks good, I’ll just go gather my equipements /

Part 2. Treatment Room

● 2nd CHECK Complete second check / with 2nd Nurse

Part 3. Back to Patient’s Room

● H&H Perform quick hand hygiene while talking to patient

Part 1. Patient’s Room

● SAFETY “I can see that the scene is safe to approach

● “Have you taken this medication before?”

● Take a quick look at the preferred site if it’s good to use