Checklist For Ha Students

Checklist for Patient Interview
Preparatory Phase
(Pre-interaction Phase)
Done
1. Nurse must collect background information from previous charts.

2. Ensure environment is conducive for interviewing
3. Arrange seating. The nurse and patient should be 4 5 feet
apart and of the same level.
4. Allow adequate time for the interview.
Introductory Phase
(Orientation Phase)
1. Nurse introduces self to the patient
2. Patient identifiers
3. Obtains consent
4. Provides purpose of interview (goal or task to be attained)
5. Ensure confidentiality of information
6. Attends to patients needs before starting
Establish rapport with the patient
5
5
4
Working Phase
(Maintenance Phase)
1. Nurse gathers information for subjective data
2. Demonstrate excellent communication skills
Active listening
Eye contact
Employing open-ended questions
Use of language understood by the patient
1.
2.
3.
4.
5.
6.
Termination Phase
(Concluding Phase)
Inform the patient that the interview is about to end.
Review goal or task attainment
Ensure that the patient knows what will happen with the
information
Offer patient a chance to ask questions or add anything to what
has been shared.
Summarize the highlights of the interview and the meaning to the
nurse and the patient.
Express gratitude after the conduct of the interview.
Repeated Repeated
once
2x and
more
2.5
2.5
2
4
5
8
5
6
6
2
2.5
4
2.5
3
3
6
8
3
4
5
7
5
2.5
3.5
2.5
2.5
2.5
TOTAL
TOTAL GRADE
GUIDE IN RATING:
95 100
EXCELLENT
90 94
VERY GOOD
85 89
GOOD
80 84
SATISFACTORY
75 79
FAIR
Able to execute the procedure without mistake; observes the

basic principles effectively with excellent speed and technique
Able to execute the procedure properly with very limited
mistake; speed and style are adequate
Able to execute the procedure well but the speed and style
have to be improved.
Able to execute the procedure well but some of the steps still
have to be reviewed by the student
Needs more guidance and practice in performing the procedure
__________________
Clinical Instructor
Checklist for Patients Admission and Discharge

Done
ADMISSIONS
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
1.
2.
3.
4.
5.
6.
7.
8.
Welcomes patient to the unit

Introduction of staff to patient
Health history taking and VS taking by the nurse
Unit physical set-up orientation (call light system, room, bed
gadgets, nurses station)
Orientation to different staff ( other members of the health
care team) & staff routines
Orientation to meal times
Orientation to patients bill of rights ( give patients copy if
possible)
Orientation to MD rounds & time of MD rounds
Noting of the MD admission orders
Inventory of patients belongings
Obtains patients consent for patients health information
release
Nursing documentation of patient admission
TOTAL
DISCHARGE
Renders health teachings (meds, diet/feeding, activities,
wound care, self-care, precautions)
Reminder of date of ff-up check up
Giving of prescriptions (made by the MD) to the patient
Inventory of patients belongings
Completions of patients satisfactory survey form regarding
feedback of hospital services rendered
Arrangement of transportation to patients destination
Assisting patient via wheelchair/ stretcher to the hospital
lobby to the vehicle
Nursing documentation of patient discharge
TOTAL
TOTAL GRADE
Repeated
once
5
5
6
4
2.5
2.5
3
2
2.5
4
6
2
3
4
5
6
6
2
2.5
3
3
2.5
2.5
4
5
6
4
2
2.5
3
2
4
5
2
2.5
Repeated
2x and
more
GUIDE IN RATING:
95 100
EXCELLENT
90 94
VERY GOOD
85 89
GOOD
80 84
SATISFACTORY
75 79
FAIR
Able to execute the procedure without mistake; observes the basic

principles effectively with excellent speed and technique
Able to execute the procedure properly with very limited mistake;
speed and style are adequate
Able to execute the procedure well but the speed and style have to
be improved.
Able to execute the procedure well but some of the steps still have
to be reviewed by the student
Needs more guidance and practice in performing the procedure
________________________
Clinical Instructor
UNIVERSITY OF SANTO TOMAS COLLEGE OF NURSING

Performance Checklist
Name _______________________
Year & Section_____
ASSESSING THE THORAX and LUNGS

Equipment:
1. Stethoscope
Nursing Action
100 points
1. Identify patients identity and introduce yourself. Explain to the

patient what you are going to do.
2. Perform hand washing technique and observe infection control
procedures.
3. Provide for patient privacy.
4. Ask the patient if he/she has any history of the following:
a. Allergies
b. Medication taken
c. History of smoking
d. Coughs, wheezing, pain
Posterior Thorax
Inspection
5. Assist the patient to stand.
6. Inspect the shape and symmetry of the thorax from
the posterior
and lateral views. Take note of the AP diameter to the transverse
diameter
7. Position yourself at the lateral aspect of the patient and take note of
the spinal curvature.
8. Instruct him/her to bend forward at the waist and observe from
behind.
Palpation
9. Assist the patient in a sitting position with arms on each side.
10. Rub your hands together and lay it gently on the patient.
11. For a patient WITH respiratory complaints, palpate all chest areas by
placing the palmar surface of the fingers and finger pads of one
hand.
If the patient complains of pain AVOID deep palpation on the
painful areas
12. Palpate the posterior chest for respiratory excursion.
a. Stand behind the patient and place your thumb at the level of
T10 along the spinal process about 5 cm apart while your hands
grasping the lateral rib cage.
b. Slide your hand medially to form small skinfold between thumbs.
c. Ask the patient to take a deep breath.
d. Watch your thumb divurge during quiet and deep breathing and
observe for symmetry of movements.
e. States significance of findings
13. Palpate the chest for vocal (tactile) fremitus
a. Place the palmar surfaces of your fingers or the ulnar aspect of
your hand or closed fist on the posterior chest, starting near the
apex of the lungs.
b. Instruct the patient to repeat words such as 99, tres tres
c. Repeat the two steps, moving your hands sequentially to the
base of the lungs.
d. States significance of findings
14. Percuss the Thorax
a. Instruct the patient to bend head forward, arms folded across
the chest with hands resting over shoulders.
b. Locate for the intercostal spaces.
c. Middle finger should be positioned parallel to the ribs in the
intercostal space
Done
Incorrectly
Repeated
0.5
1.0
0.5
1.0
0.5
1.0
1.0
0.25
0.5
0.5
1.0
0.25
0.5
0.5
1.0
0.25
0.25
0.5
0.5
0.5
1.0
1.0
2.0
1.0
2.0
0.5
1.0
0.5
1.0
1.0
2.0
1.0
2.0
1.0
2.0
1.0
2.0
1.0
2.0
1.0
2.0
1.0
2.0
1.0
2.0
d. Place your nondominant hand on the surface of the body with

fingers slightly spread.
e. The distal phalanx of the middle finger (pleximeter finger) placed
firmly on the body surface with the other fingers slightly off the
surface.
f. Using the tip of your plexor finger (striking finger), tap the
interphalyngeal joint of the pleximeter finger by the downward
snap of your wrist.
g. Tap should be sharp and rapid with relaxed wrist motion.
h. Compare on the opposite intercostal space
i. States significance of findings
15. Auscultate the chest using the flat-disc diaphragm of the
stethoscope.
a. Warm the flat-disc diaphragm by rubbing it against your palm
before placing it to the patients skin.
b. Ask the patient to take slow, deep breaths through the mouth.
c. Listen at each point where each breath sounds are well
appreciated during a complete respiratory cycle.
d. Be alert for patients comfort.
e. Compare the findings at each point and take note for the
deviation of the sound heard.
f. States significance of findings
Anterior Thorax
Inspection
1. Position patient in an upright position with shoulders arched
backward and arms on each side.
2. Inspect breathing patterns.
3. Inspect the costal angle and ribs.
4. Palpate the anterior chest for respiratory excursion:
a. Place the palms of your hands on the lower thorax while your
fingers along the rib cage laterally and your thumbs along the
costal margins.
b. Ask the patient to take a deep breath and
observe the movement of your hands.
5. Palpate tactile fremitus in the same manner as for
the posterior chest:
6. Percuss the anterior chest
a. Position patient in an upright position with shoulders arched
backward and arms on each side
b. Begin above the clavicles in the supraclavicular space, and
proceed downward to the diaphragm.
c. Place the pleximeter finger in the intercostal space parallel to
the ribs.
d. Percuss the thorax using proper percussion technique
e. Compare one side of the lung to the other.
7. Auscultate the trachea.
a. Place the stethoscope over the trachea above the suprasternal
notch.
b. Move the stethoscope on each side of the trachea, just above
each sternoclavicular joint.
8. Auscultate the anterior chest:
a. Use the sequence used in percussion, beginning over the
bronchi between the sternum and the clavicles.
b. Move down to the sixth intercostal space and laterally to the
mid-axillay line
c. Move the stethoscope from side to side as you move down and
compare sounds.
9. End of Examination
a. Inform patient that examination is done
b. Assist patient in dressing up
c. Says Thank You
10. Document findings in the patient record.
TOTAL SCORE
TOTAL GRADE
1.0
2.0
1.0
2.0
1.0
2.0
1.5
1.0
1.0
3.0
2.0
2.0
1.0
2.0
1.0
2.0
1.5
3.0
1.5
3.0
1.0
2.0
1.0
2.0
1.0
2.0
1.0
1.0
2.0
2.0
1.0
2.0
1.0
2.0
1.0
2.0
1.0
2.0
1.0
2.0
1.5
3.0
1.5
1.0
3.0
2.0
1.0
2.0
1.0
2.0
1.5
3.0
1.5
3.0
1.5
3.0
0.5
0.5
0.5
0.5
1.0
1.0
1.0
1.0
GUIDE IN RATING:
95
100
90 94
85 89
80 84
75 79
EXCELLENT
Able to execute the procedure without mistake. Observes the basic

principles effectively with excellent speed and technique.
VERY GOOD
Able to execute the procedure properly with very limited mistake, speed
and style are adequate.
GOOD
Able to execute the procedure well but the speed and style have to be
practiced.
SATISFACTORY Able to execute the procedure well but some of the steps still have to be
reviewed with the student.
FAIR
Needs more guidance and practice in performing procedure.
UNIVERSITY OF SANTO TOMAS

COLLEGE OF NURSING
ASSESSING THE HEART AND CENTRAL VESSELS
NAME ____________________________
Equipment:
Year & Section ______________
Stethoscope
Ruler #2
Nursing Action
100 points
1. Introduce yourself, and verify patients identity. Explain to the patient what you are
going to do and they will need to assume different positions (sitting erect and
leaning forward, lying supine and left lateral recumbent).
2. Perform hand hygiene, and observe other appropriate infection control procedures.
4. Inquire if the patient has any history of the following:
Family history of incidence and age of heart disease, high cholesterol
levels, high blood pressure, stroke, obesity, congenital heart disease,
arterial disease, hypertension, and rheumatic fever
Patients past history of rheumatic fever, heart murmur, heart attack,
varicosities, or heart failure
Present symptoms indicative of heart disease
Presence of diseases that affect the heart
Lifestyle habits that are risk factors for cardiac disease
Assessment
5. Inspection
a. Position patient supine with head of bed elevated at 30 degrees.
b. Observe for the apical impulse and any abnormal pulsations.
c. States significance of findings
a. Warm your hands by rubbing it together before touching patient.
b. With the patient supine, locate for the Point of Maximal Impulse (apical impulse)
using your fingerpads.
c. If pulsations cannot be palpated in the supine position, ask the patient to
assume a left lateral position.
d. Use your palmar surface to palpate over the:
d.1. right sternal border 2nd intercostals space.
d.2. left sternal border 2nd intercostal space
d.3. left sternal border, 3rd then 4th intercostals space
d.4. apex, MCL, 5th ICS
d.5 epigastric area, below the xiphoid process.
6. Auscultation
a. Make certain the patient is warm and relaxed.
b. Warm stethoscope before placing it onto patient
c. Using the diaphragm of the stethoscope, apply firm pressure and auscultate
on the following areas:
c.1 2nd right ICS, RSB
- Describe the 1st heart sound in this region
- Describe the 2nd heart sound in this region
c.2 2nd left ICS, LSB
c.3 3rd left ICS, LSB
c.4 4th left ICS, LSB
c.5 5th left ICS, MCL
Done
correctly
Repeated
1.0
0.5
1.0
1.0
0.5
0.5
2.0
1.0
1.0
1.5
2.0
1.0
0.5
.75
1.0
0.5
2.0
1.0
1.0
0.5
3.0
1.5
3.0
3.0
3.0
3.0
1.5
1.5
1.5
1.5
2.0
1.0
1.0
1.0
0.5
0.5
3.0
2.0
2.0
3.0
2.0
2.0
3.0
2.0
2.0
3.0
2.0
2.0
3.0
2.0
2.0
1.5
1.0
1.0
1.5
1.0
1.0
1.5
1.0
1.0
1.5
1.0
1.0
1.5
1.0
1.0
d. Using the bell of the stethoscope, apply light pressure over the designated
auscultatory areas and epigastric region.
7. Carotid Arteries
I. Inspection
Ask the patient to raise chin slightly, keeping the head straight. Inspect for obvious
pulsations of artery.
II. Palpation
a. Ask patient to turn head slightly away from artery being examined.
b. With your index and middle fingers palpate each carotid artery at the medial
angle of the sternocleidomastoid muscle.
c. Repeat on the other side.
d. States normal from abnormal
III. Auscultation
Place the bell of the stethoscope over each artery. Ask the patient to hold a breath for
a few heartbeats so that respiration will not interfere with auscultation.
IV. Compare the apical pulse to a carotid pulse. Auscultate the apical pulse while
simultaneously palpating a carotid pulse. Compare the findings.
8. Jugular Veins
a. With the patient sitting upright, turn patients head slightly away from the side you
are examining. With tangential lighting, look for the internal and external jugular
veins.
If the jugular vein is visible:
a. Palpate the patients radial pulse and establish if these pulsations coincide
with the radial pulse.
b. Place patient in a supine position at 30 450 angle and inspect for jugular vein
distention.
c. With 2 rulers, place one ruler vertically at the angle of Louis while the other
ruler placed horizontally onto the height of the distention.
d. Assess the height of the elevation in centimeters from the vertical ruler.
e. State significance of findings
3.0
1.5
2.0
1.0
2.0
1.0
1.0
0.5
2.0
1.0
2.0
2.0
1.0
1.0
2.0
1.0
2.0
1.0
2.0
1.0
2.0
1.0
2.0
1.0
1.5
0.75
1.5
0.75
1.5
0.75
1.0
1.0
1.0
1.0
0.5
0.5
0.5
0.5
9. Ending the Examination

c. Says Thank You
10. Document findings
TOTAL SCORE:
GUIDE IN RATING
95 100
EXCELLENT
90 94
VERY GOOD
85 89
80 84
GOOD
SATISFACTORY
75 79
FAIR
Able to execute the procedure without mistake observing the basic principles
effectively with excellent speed and technique
Able to execute the procedure properly with very limited mistake, speed and
style are adequate
Able to execute the procedure well but the speed and style has to be practiced
Able to execute the procedure well but some of the steps still has to be reviewed
with the student
Needs more guidance and practice in performing procedure
__________________________
Clinical Instructor

COLLEGE OF NURSING
ASSESSMENT OF THE PERIPHERAL VASCULAR SYSTEM
NAME ____________________________
Equipment:
Year & Section ______________
Tourniquet
Done
correctly
Repeated
1.0
0.5
1.0
1.0
0.5
0.5
2.0
1.0
2.0
1.0
3.0
1.5
3.0
1.5
2.0
1.0
2.0
1.0
b. Release the pressure

c. Note the time the nailbed regains its full color
10. Palpate peripheral pulses
a. Palpate individually the brachial, radial and ulnar artery simultaneously on
both sides using firm pressure of the index and middle fingers.
2.0
2.0
1.0
1.0
4.0
2.0
b. Note the characteristics of peripheral pulses.

c. Identify normal from abnormal
11. Palpate the adequacy of blood flow by performing the Allens Test
a. Position patients palm facing upward
3.0
3.0
1.5
1.5
2.0
1.0
2.0
1.0
2.0
1.0
3.0
3.0
3.0
1.5
1.5
1.5
Nursing Action
100 points
1. Identify patients identity and introduce yourself. Explain to the patient what you
are going to do.
2. Perform hand washing technique and observe infection control procedures.
4. Ask the patient if he/she has any history of the following:
> hypertension, heart disease, stroke, diabetes
> leg cramps, swelling in one or both feet,
> changes in skin color, size and temperature
> non-healing wound
ASSESSMENT: Upper Extremities
Inspection
5. Inspect the arms and note changes in skin color, texture, distribution of hair, size,
and presence of edema, varicosities and ulcerations and clubbing of nailbeds.
6. To assess nail clubbing Schamroth Technique
a. Ask the patient to bring the dorsal surface of nail of corresponding finger,
creating a mirror image.
7. Observe for the presence of a diamond-shape window in between fingers.
Palpation
8. Palpate for temperature on both sides simultaneously using the dorsum of the
hand beginning from the periphery to the proximal region.
9. Check for capillary refill
a. Blanched the fingernail with sustained pressure for a few seconds.
b. Compress the radial and ulnar artery with your thumbs or with your index and
middle fingers
c. Have the patient open and close fist for several times till it blanches then
leave it open.
d. Release pressure in the ulnar artery and observe for palmar reperfusion.
e. Repeat procedure this time release the pressure in the radial artery.
f. Significance of findings
ASSESSMENT: Lower Extremities
Inspection
12. Inspect the legs and note changes in skin color, texture, distribution of hair, size,
presence of edema, varicosities and ulcerations
Palpation
13. Palpate for temperature on both legs simultaneously using the dorsum of the
hand beginning from the periphery to the proximal region.
14. a. Palpate the:
a. dorsalis pedis
b. posterior tibialis
c. popliteal pulse
b. Note the characteristics of peripheral pulses.
2.0
1.0
2.0
1.0
3.0
1.5
3.0
3.0
2.0
1.5
1.5
1.0
c. Significance of findings
9. Palpate for pitting edema
a. Press your index finger /thumb on the area of swelling for several seconds.
2.0
1.0
3.0
1.5
b. Note if the depression rapidly refills and resumes to its original contour.
c. Grade the edema (if present).
Assessment of Venous Obstruction and Insufficiency
10. Homans Sign
a. Flex the knee slightly with one hand
3.0
3.0
1.5
1.5
3.0
1.5
b. Dorsiflex the foot with the other hand

c. Ask patient to report any pain.
d. Identify normal from abnormal
11. Manual Compression (If varicose veins are present)
a. Ask the patient to stand
3.0
3.0
1.0
1.5
1.5
0.5
2.0
1.0
2.0
1.0
2.0
1.0
2.0
1.0
2.0
2.0
1.0
1.0
b. Palpate the lower portion of the varicose vein with the index and middle
finger of your one hand. Keep the hand on the vein.
c. With the index and middle finger of your other hand, compress firmly the vein
about 15 20cm above the lower hand and feel for pulsations in the upper
hand.
12. Trendelenburg Test
a. Ask patient to lie supine and elevate legs at least 90 degrees for about 15
seconds.
b. Place a tourniquet around the upper thigh.
c. Ask the patient to stand and observe for filling of the veins.
d. Release the tourniquet after 20 30 seconds standing then observe for filling
of the veins.
c. Says Thank You
14. Documents findings
TOTAL SCORE
2.0
1.0
1.0
1.0
1.0
1.0
0.5
0.5
0.5
0.5
Guide in Rating
95 100
EXCELLENT
90 94
VERY GOOD
85 89
80 84
GOOD
SATISFACTORY
75 79
FAIR
Able to execute the procedure without mistake observing the basic principles
effectively with excellent speed and technique
Able to execute the procedure properly with very limited mistake, speed and
style are adequate
Able to execute the procedure well but the speed and style has to be practiced
Able to execute the procedure well but some of the steps still has to be reviewed
with the student
___________________________
Clinical Instructor

COLLEGE OF NURSING
ASSESSING THE NEUROLOGICAL SYSTEM
NAME __________________________
Year & Section ___________
Equipment:
> Sugar, salt, lemon, coffee
> Percussion hammer
> Tongue depressors
> Wisps of cotton
> Test tubes of hot and cold water
> Paper clip
Nursing Action
100 points
1. Assemble equipment:
Sugar, salt, lemon juice, quinine flavors
Percussion hammer
Tongue depressors (one broken
diagonally, for testing pain sensation)
Wisps of cotton, to assess light touch
sensation
Test tubes of hot and cold water, for skin
temperature assessment (optional)
Pins or needles for tactile discrimination
Procedure
1. Introduce yourself, and verify the patients identity.
Explain to the patient what you are going to do, why it
is necessary, and how the patient can cooperate.
2. Perform hand hygiene, and observe other appropriate
infection control procedures.
4. Inquire if the patient has any history of the following:
a. Presence of pain in the head, back, or
extremities, as well as onset and aggravating
and alleviating factors
b. Disorientation to time, place or person
c. Speech disorders
d. Any history of loss of consciousness, fainting,
convulsions, trauma, tingling, or numbness,
tremors or tics, limping, paralysis, uncontrolled
muscle movements, loss of memory, or mood
swings
e. Problems with smell, vision, taste, touch, or
hearing
Language
5. Ask patient and observe and listen to tone, clarity and
pace of speech.
6. If the patient displays difficulty speaking:
a. Point objects in the room and ask patient to
name them.
b. Ask the patient to read from a printed material
apt for his/her educational level
c. Ask the patient to respond to simple verbal and
written commands - e.g., Point to your toes,
or Raise your left arm.
Done
correctl
y
Repeate
d
3.0
1.5
1.0
0.5
1.0
0.5
1.0
0.5
3.0
1.5
0.5
0.25
0.5
0.25
0.5
0.25
0.5
0.25
Not
Done
Done
Incorrectl
y
Orientation
7. Determine patients orientation to:
Person ask patients name or names of family
members.
Place ask patients home address, Where the
0
3.0
1.5
patient is now.
Time ask patient the date today, hour, day or
season.
Memory
8. Listen for lapses in memory.
Ask the patient about difficulty with memory. If problems are apparent, three categories of memory are
tested: immediate recall, recent memory, and remote memory.
To assess immediate recall:
Ask the patient to repeat a series of three digits
e.g., 7-4-3 spoken slowly.
Gradually increase the number of digits e.g.,
7-4-3-5, 7-4-3-5-6, and 7-4-3-5-6-7-2 until the
patient fails to repeat the series correctly.
Start again with a series of three digits, but this
time ask the patient to repeat them backward.
To assess recent memory:
Ask the patient what the weather is like today,
what medications did he took just now, what is
the name of the doctor who visited him today.
To assess remote memory:
Ask patients about events in the past (e.g. bdays, anniversaries, educational dates and
events, surgeries).
Attention Span and Calculation
9. Test the ability to concentrate or attention span by
asking the patient to spell a word forward and
backward.
10. Test the patients ability to perform Arithmetic
calculations beginning with simple Addition and
multiplication to more difficult two-digit calculations.
Level of Consciousness
11. a. Call the patients name and observe the response.
If the patient did not respond call their name louder or
you may shake the patient. If still no response apply a
painful stimulus.
b. State the level of consciousness
c. Describe the different levels of consciousness
12. a. For patients who are at high risk of rapid nervous
system deterioration, apply the Glasgow Coma Scale
given a scenario:
a.1. Eye response
a.2. Motor response
a.3. Verbal response
b. Rate the GCS and state significance of findings
Cranial Nerves
13. Cranial Nerve I Olfactory
a. Ask the patient to clean nose then close eyes.
b. Occlude one nostril and identify different mild
odors.
c. Repeat the procedure for the other nostril.
d. State significance of findings
0.5
0.25
0.5
0.25
0.5
0.25
0.5
0.5
0.25
3.0
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0
0
0
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2.0
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1.0
1.0
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0.25
0.5
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0.5
14. Cranial Nerve II Optic

1.1. Test for near vision ask the patients to read a
magazine, observe closeness or distance of the page
to the patients face.
0.25
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1.0
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1.5
3.0
1.0
2.0
1.2. Test for distant vision position patient 20 feet from

the Snellen chart and ask her to read each line until
0
they cannot read the letters.
1.3. Test for visual fields by confrontation
a. position yourself about 2 feet away from the
0
patient at eye level.
b. ask the patient to cover his left eye while you
0
cover your right eye.
c. ask the patient to look at your uncovered eye.
0
d. fully extend your left arm at midline and slowly
move one finger upward from below until the
0
patient sees your finger.
e. test the remaining three visual fields of the
0
patients right eye.
f. repeat the test on the opposite eye
0
15. Cranial Nerve III, IV and VI (Oculomotor, Trochlear and Abducens)
15.1. Inspect margins of the eyelids of each eye
(CNIII)
15.2. Assess extraocular movements: six cardinal
fields (CN III, IV, VI)
a. stand at 2 feet in front of patient.
b. instruct the patient to focus on the object you
are holding.
c. move the object through the six cardinal
positions of gaze (H method or wagon wheel
method) in a clockwise direction and observe
the patients eye movements.
15.3. Assess pupillary response and
accommodation (CN III)
a. assess size and shape of pupils
b. Interpret findings
15.3.1. To light direct response
a. Dim the room.
b. Ask patient to look on a distant object
c. Shine a light obliquely into one eye
d. Observe the pupillary reaction
e. Interpret findings
15.3.2. Consensual response
a. Shine a light obliquely into one eye and
observe the pupillary reaction in the
opposite eye.
15.4. Test accommodation and convergence of
pupils
a. Hold your finger or a pencil 12 to 15 inches
from the patient.
b. Instruct the patient to focus on your finger
or pencil and to remain focused on it as
you move it closer toward the eyes.
15.5. Document findings using the abbreviation
PERRLA.
16. Cranial Nerve V Trigeminal
16.1 Test motor function
a. Instruct the patient to clench their teeth while
you palpate the temporal and masseter muscles for
contraction
16.2 Test for sensory function

Deep sensation
a. Advice patient that you will touch his forehead,
cheeks and chin with the sharp or dull end of a
paper clip.
b. Ask patient to close his eyes.
c. Touch each side of the forehead, cheek and
chin areas alternately using the sharp and dull
end of the paper clip. Avoid a predictable
pattern.
d. Ask the patient to report whether the sensation
is sharp or dull.
16.3 Light sensation
a. With the same six areas as deep
sensation, stroke the face with a cotton
wisp.
b. Ask the patient to tell when the sensation
is felt.
16.4 Test for Corneal Reflex
a. Ask patient to remove contact lenses if
used.
b. Have the patient to look up and away from
you as you approach from the side.
c. Lightly touch the cornea of one eye with a
cotton wisp avoiding the eyelashes and
conjunctiva.
d. Repeat the procedure on the other cornea.
17. Cranial Nerve VII Facial
Ask the patient to assume different facial
expressions (smile, frown puff out cheeks).
18. Cranial Nerve VIII Auditory
18.1 Whispered Voice
a. Ask the patient to cover one ear
b. Stand about 1-2 ft away from the side of the
ear being tested and out of patients line of
vision.
c. Whisper a combination of three numbers and
letters in random.
d. Ask the patient to repeat what you have
spoken.
e. Repeat the process with the other ear
18.2 Perform the Webers Test
a. Strike a tuning fork and place the base of
the vibrating tuning fork on the midline of
the patients head or forehead.
b. Ask the patient if sound is heard equally in
both ears or is better in one ear
(lateralization of sound)
18.3 Perform the Rinne Test
a. Place the base of the vibrating tuning fork
on the patients mastoid process and ask
the patient to tell you when the sound is no
longer heard. Time the interval of bone
conduction.
b. When the sound is no longer heard,
quickly position the still vibrating tines 1 -2
cm from the auditory canal, and ask the
patient to tell you when the sound is no
longer heard. Time the interval of air
conduction.
c. Compare the number of seconds sound is
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1.0
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1.0
2.0
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1.0
1.0
2.0
1.0
2.0
0.5
1.0
0
0
heard by bone conduction versus air

conduction.
19. Cranial nerve IX and X Glassopharyngeal and Vagus
19.1 Test motor function:
a. ask the patient to say ah with mouth wide
open while you use a tongue depressor on
the patients tongue.
b. Observe for the uvula and soft palate
19.2 Test the gag reflex:
a. Warn patient that the test may feel a little
uncomfortable.
b. With the use of the tongue depressor,
touch the posterior pharynx.
20. Cranial Nerve XI Accessory
a. Ask the patient to shrug the shoulders against
resistance.
b. Ask the patient to turn head against resistance
first to the right then to the left.
21. Cranial Nerve XII Hypoglossal
a. Inspect patients tongue while at rest on the
floor of the mouth and while protruding from
the mouth.
b. Ask the patient to protrude tongue and move it
from side to side.
c. Ask the patient to push the tongue against the
cheek as you apply resistance with an index
finger.
TOTAL SCORE
REFLEXES:
100 points
22. Biceps Reflex

a. Partially flex the patients arm at the elbow,
and rest the forearm over the thighs, placing
the palm of the hand down.
b. Palpate the biceps tendon in the antecubital
fossa.
c. Place the thumb of your non-dominant hand
horizontally over the biceps tendon while your
fingers under the elbow.
d. Deliver a blow (slight downward thrust) with the
percussion hammer to your thumb.
e. Observe the normal slight flexion of the elbow,
and feel the biceps contraction through your
thumb.
23. Triceps Reflex
a. Flex the patients arm at the elbow, and
support it in the palm of your non-dominant
hand.
b. Palpate the triceps tendon about 2-5 cm (1-2
inches) above the elbow.
c. Deliver a blow with the percussion hammer
directly to the tendon.
d. Observe for the normal slight extension of the
elbow.
24. Brachioradialis Reflex
0.5
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Not
Done
Done
Incorrectl
y
Done
correctl
y
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Remark
s
a. Rest the patients arm on your forearm or on

the patients own leg with the hand slightly
pronated.
b. Tap the tendon at the radius 2-5cm above the
wrist.
c. Observe the normal flexion and supination of
the forearm. The fingers of the hand might also
extend slightly.
25. Patellar Reflex
a. Ask the patient to sit on the edge of the
examining table and let both legs hang freely.
b. Locate the patellar tendon directly below the
patella.
c. Stand on the side of the patient and ask the
patient to look up or to interlock fingers and
pull.
d. Deliver a blow with the percussion hammer
directly to the tendon just below the patella.
e. Observe the normal extension or kicking out of
the leg as the quadriceps muscle contracts.
26. Achilles Reflex
a. With the patientrs leg still hanging freely,
slightly dorsiflex the patients ankle by
supporting the foot lightly in your hand.
b. Deliver a blow with the percussion hammer
directly to the Achilles tendon just above the
heel.
c. Observe and feel the normal plantar flexion
(downward jerk) of the foot
27. Able to state reflex scoring
0.5
1.0
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28. Plantar (Babinskis) Reflex

The plantar or Babinskis reflex is superficial. It might be absent in adults without pathology or
overridden by voluntary control.
a. With the end of the reflex hammer or a key,
stroke the lateral border of the sole of the foot
0
1.5
3.0
beginning from the heel towards the ball of the
foot, curving medially across the ball.
b. Identify normal from abnormal findings.
29. Meningeal Signs:
Neck Mobility
a. Make sure there is no injury to the cervical
vertebrae or cervical cord
b. With the patient supine, place your hands
behind the patients neck forward until the chin
touches the chest if possible,
c. Identify normal from abnormal findings
Brudzinskis Sign
a. As you flex the neck, watch the hips and knees
in reaction to your maneuver
b. Identify normal from abnormal findings
Kernigs sign
a. Flex the patients leg at both the hip and the
knee, and then straighten the knee.
b. dentify normal from abnormal findings
c. Identify significance of findings
Motor Function
1.5
3.0
1.0
2.0
1.0
2.0
1.0
2.0
1.0
2.0
1.0
2.0
1.0
2.0
0
0
1.0
1.0
2.0
2.0
Assessment
30. Gross Motor and Balance Tests
Walking Gait
Ask the patient to walk naturally across the room
and back, and assess the patients gait.
(patient should not be aware that you are
observing them)
Rombergs Test
a. Ask the patient to stand with feet together arms
resting at the sides, with eyes open then
closed.
b. Stand close to the patient during this test.
c. Note any unsteadiness or swaying.
Standing On One Foot With Eyes Closed
a. Ask the patient to stand on one foot with eyes
closed and arms straight on each side.
b. Repeat with the other foot.
c. Stand close to the patient during this test.
Heel-Toe Walking
a. Ask the patient to walk a straight line, placing
the heel of one foot directly in front of the toes
of the other foot.
b. Stand close by in case the patient loses
balance.
Toe or Heel Walking
Ask the patient to walk several steps on the toes
and then on the heels.
31. Fine Motor Tests for the Upper Extremities
Finger-to-Nose Test
a. Ask the patient to abduct and extend arms at
shoulder height and rapidly touch nose
alternately with one index finger and then the
other.
b. Have the patient repeat the test with eyes
closed if the test is performed easily.
Alternating Supination and Pronation of Hands
on Knees
Ask the patient the pat both knees with the palms
of the hand alternate with the back of the hands, at
an increasing rate.
Finger to Nose and to the Nurses Finger
Ask the patient to touch their nose and then your
index finger held at about 45 cm, at a rapid and
increasing rate at different direction.
Fingers to Fingers
Ask the patient to spread arms approximately at
shoulder height then bring fingers together at
midline with eyes open then with eyes closed, first
slowly then rapidly.
Fingers to Thumb (Same Hand)
Ask the patient to touch each finger of one hand to
the thumb of the same hand as rapidly as possible.
32. Fine Motor Tests for the Lower Extremities
Ask the patient to lie supine and to perform these tests:
Heel Down Opposite Shin
a. Ask the patient to place the heel of one foot
just below the opposite knee and run the heel
down the shin to foot.
b. Repeat with the other foot. The patient may
0.5
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1.0
0
0
1.0
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0
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also use a sitting position for this test.

Toe or Ball of Foot to the Nurses Finger
Ask the patient to touch your finger with the large
toe of each foot with your fingers moving at
different directions.
0.5
1.0
33. Light-Touch Sensation

Compare the light-touch sensation of symmetric areas of the body.
a. Ask the patient to close eyes and instruct to
say, yes or now whenever the patient feels
0
0.5
1.0
the cotton wisp touching the skin.
b. With a wisp of cotton, lightly touch one specific
spot of the body and then the same spot on the
0
0.5
1.0
other side of the body.
c. Test areas on the forehead, cheek, hand,
lower arm, abdomen, foot, and lower leg.
0
0.5
1.0
Check a distal area of the limb first.
d. Ask the patient to point to the spot where the
0
0.5
1.0
touch was felt.
e. If areas of sensory dysfunction are found,
determine the boundaries of sensation by
testing responses approximately every 2.5 cm
0
0.5
1.0
(1 inch) in the area. Make a sketch of the
sensory loss area for recording purposes.
34. Pain Sensation
Assess pain sensation as follows:
a. Ask the patient to close his/her eyes and to
0
0.5
1.0
say, sharp, dull, or dont know when the
sharp or dull end of paper clip is felt.
b. Test and let patient feel the sensation first
0
0.5
1.0
before proceeding.
c. Alternately apply the sharp and dull end of the
paper clip at chosen anatomic areas randomly.
0
0.5
1.0
The face is not tested in this manner.
d. Allow at least two seconds between each test.
0
0.5
1.0
35. Temperature Sensation
a. Ask the patient to say hot, cold or dont
know as you touch the areas of the skin with
0
0.5
1.0
hot or cold water - filled test tubes.
36. Position or Kinesthetic Sensation
Commonly, the middle fingers and the large toes are tested for kinesthetic sensation.
a. Ask the patient to close his/her eyes
b. To test the fingers, support the patients hand
with one hand and grasp the patients middle
finger between the thumb and index finger of
your other hand exerting the same pressure on
both sides of the fingers.
To test the large toe, grasp the large toe with
your thumb and index finger exerting the same
pressure on both sides of the toe.
c. Using a series of brisk up-and-down
movements bring the fingers or large toe to a
sudden stop in one of the three positions (up,
down, or straight out).
d. Ask the patient to identify the position of the
middle finger or large toe.
37. Tactile Discrimination
For all tests, the patients eyes need to be closed:
One-and Two-point discrimination
a. Using the ends of a two paper clip,
0.5
1.0
0.5
1.0
0.5
1.0
0.5
1.0
0.25
0.5
simultaneously touch a finger pad in two

places then alternate it with a one-point touch
irregularly.
b. Ask the patient whether they feel one or two
points of stimulus.
c. With a two point stimulus, gradually decrease
the distance of each point and ask patient
whether they perceive one or two point
stimulus.
d. Perform the same procedure in the hands and
feet and lower legs.
Stereognosis
a. Direct patient to close both eyes
b. Place familiar objects such as a key, paper
clip, or coin in the patients hand, and ask the
patient to identify them.
If the patient has a motor impairment of the
hand and is unable to manipulate an object
perform:
Graphesthesia
a. Direct patient to keep both eyes closed.
b. Using the base of a pen, draw a number/letter
into the palm of the patients hand.
c. Be sure the number/letter faces the patient.
d. Ask the patient to identify the inscription.
Extinction Phenomenon/Topognosis
a. Simultaneously stimulate two symmetric areas
of the body, such as thighs, the cheeks, or the
hands.
b. Ask patient to identify what part of the body
was involved
c. Also ask to point to the area you touched.
a. Informs patient that examination is done.
b. Assists patient in dressing up.
c. Says Thank You
TOTAL SCORE
0.25
0.5
0.5
1.0
0.25
0.5
0.5
1.0
0.5
1.0
0.5
1.0
0.25
0.5
0
0
1.0
0.5
2.0
1.0
0.25
0.5
0.25
0.5
0.25
0.5
0
0
0
0
0.5
0.5
0.5
0.5
1.0
1.0
1.0
1.0
Guide in Rating
95 100
EXCELLENT
90 94
VERY GOOD
85 89
GOOD
80 84
SATISFACTORY
75 79
FAIR
Able to execute the procedure without mistake observing the basic

Able to execute the procedure properly with very limited mistake,
Able to execute the procedure well but the speed and style has to
be practiced
Able to execute the procedure well but some of the steps still has
to be reviewed with the student
___________________________
Clinical Instructor

COLLEGE OF NURSING
ASSESSING THE ABDOMEN
NAME ____________________________
Year & Section __________
Equipment: Stethoscope
Penlight
Tape Measure
Skin Marker
Preparation
100 points
Examining light
Tape measure (metal or unstretchable
cloth)
Water-soluble skin-marking pencil
Stethoscope
Procedure
1. Introduce yourself, and verify the patients
identity. Explain to the patient what you are going
to do, why it is necessary, and how the patient
can cooperate.
2. Perform hand hygiene, and observe other
appropriate infection control procedures.
4. Inquire if the patient has any history of the
following:
a. Incidence of abdominal pain: its location,
onset, sequence, and chronology; its
quality (description); its frequency;
associated and the symptoms
b. Bowel habits
c. Incidence of constipation or diarrhea
d. Change in appetite
e. Food intolerances
f. Foods ingested in the last 24 hours
g. Specific signs and symptoms
h. Previous problems and treatment
5. Position patient
a. Assist patient to a supine position. Place a
small pillow under the head and beneath the
knees whiles the hands on the side or folded
across the chest.
b. Expose the abdomen from the xiphoid
process to the level of the symphysis pubis.
Assessment
Inspection of the Abdomen
6. Inspect the abdomen for skin integrity.
1. Inspect the abdomen for contour and symmetry.
a. While at the patients side, sit or bend down
to view the contour of the abdomen.
b. Ask the patient to take a deep breath and to
hold it.
c. Assess the symmetry of contour while
standing at the foot of the bed.
d. If distention is present, measure the
abdominal girth by placing a tape around the
Not
Done
Done
Incorrectly
Done
0.5
1.0
0.5
1.0
0.5
1.0
0.5
1.0
1.0
2.0
1.5
3.0
1.5
3.0
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1.0
0.5
1.0
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1.0
0.5
1.0
1.5
3.0
Remarks
abdomen and measure at the level of the

umbilicus.
2. Observe abdominal movements associated with
0
1.0
2.0
respiration, peristalsis, or aortic pulsations.
3. Observe the vascular pattern.
0
0.75
1.5
Auscultation of the Abdomen
Auscultate the abdomen for bowel sounds, vascular sounds, and peritoneal friction rubs.
10. Auscultate the bowel sounds :
a. Using the diaphragm of the stethoscope
apply
0
1.0
2.0
light pressure from the right lower
quadrant then proceed clockwise for at least
60 seconds
11. Auscultate for vascular sounds
a. Use the bell of the stethoscope, apply light
pressure beginning at midline below the
0
1.0
2.0
xiphoid
process then proceed to auscultate the:
a. 1. renal arteries
a. 2. iliac arteries
0
1.0
2.0
a. 3. femoral arteries
0
0.5
1.0
12. Listening for friction rub
a. Use the diaphragm of the stethoscope,
0
0.25
0.5
place it lightly over the right and left lower rib
cage
13. Percussion of the Abdomen Percuss several areas in each of the four quadrants to
determine presence of tympany and dullness.
a. Ask patient any painful areas in the abdomen
0
1.0
2.0
b. Percuss abdomen using proper percussion
0
1.0
2.0
technique
c. Percuss abdomen in a systematic pattern:
begin in the lower left quadrant proceeding
0
1.0
2.0
clockwise.
14. Percussion of the Liver Percuss the liver to determine its size.
a. Percuss upwards beginning from below the
level of the umbilicus at mid-clavicular line,
0
0.5
1.0
right lower quadrant. Note the change from
tympany to dull. Mark this point
b. Percuss downwards from the fourth
intercostal space right mid-clavicular line and
0
0.5
1.0
note the change from resonant to dull. Mark
this point.
c. State significance of findings
0
0.5
1.0
15. Percussion of the kidney
a. Ask patient to sit or supine turned to one
0
0.5
1.0
side.
b. Place the palmar surface of your left hand at
0
1.0
2.0
the costovertebral angle.
c. Strike your left hand using the ulnar surface
0
1.0
2.0
of your right fist
d. State significance of findings.
0
1.0
2.0
16. Palpation of the Abdomen
a. Ask patient for any abdominal tenderness.
0
1.0
2.0
b. Perform light palpation first with hand held
flat & relaxed and molded to abdominal
0
1.0
2.0
wall; palpate the abdomen with a light, gentle
dipping motion.
c. Systematically explore all four quadrants.
0
1.0
2.0
d. Perform deep palpation over all quadrants.
0
1.0
2.0
17. Palpation of the Liver
Palpate the liver to detect enlargement and tenderness.
a. Place left hand under the lower portion of the

ribs
b. Tell patient to rest into your left hand.
c. Lift the ribcage with your left hand.
d. Place your right hand into abdomen, fingers
pointing toward the patients head or
somewhat oblique position.
e. Ask the patient to deep breath and with an
inward upward thrust at the costal margin of
your right hand, feel the edge of the liver with
your fingertips.
18. Palpation of the Bladder
a. Palpate the area above the pubic symphysis
if the patients history indicates possible
urinary retention.
SPECIAL TECHNIQUES
19. Rebound Tenderness (Blumbergs sign)
a. Ask patient to lie supine
b. Position hand at 900 angle to the abdominal
wall in the area of abdominal pain.
c. Press hand deeply in a slow steady
movement then rapidly remove fingers
d. Ask patient when they felt the pain.
e. State normal from abnormal findings.
20. Rovsings sign
a. Ask patient to lie supine.
b. Position hand at 900 angle, palpate on the
left lower quadrant and ask patient where
pain is felt.
c. Ask patient where they felt the pain and its
significance
21.Test for Psoas sign
a. Patient in supine position.
b. Place your right hand above the level of the
patients right knee.
c. Ask patient to raise the right leg to meet your
hand or apply resistance as patient lifts leg.
d. Ask patient if they felt pain and its
significance
22. Test for obturator sign
a. Patient in supine position
b. Flex the patients right thigh at the hip with
the knee bent.
c. Rotate the leg internally and externally at the
hip.
d. Ask patient if they felt pain and its
significance.
23. Cutaneous Hyperesthesia
a. Patient in supine position, gently pick up a
fold of skin between thumb and index finger
(without pinching) and quickly let go along
the abdominal wall.
Test for ascites
24. Fluid wave test
a. Place patient in a supine position.
b. Ask the patient or an assistance to place the
ulnar surface of their hand firmly along the
midline of the abdomen.
c. Place the palmar surface of your one hand
firmly on one side of the patients abdomen.
d. Tap the patients abdomen on the other side
0.5
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0
0
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1.0
0.5
1.0
0.25
0.5
0.5
1.0
1.0
2.0
1.0
2.0
1.0
2.0
with your other hand.

e. Feel for transmission of fluids against the
resting hand.
25. Shifting Dullness
a. Ask patient to remain supine.
b. Percuss from the flanks from the bed upward
toward umbilicus. Note change of sound
from dull to tympanic. Mark that area.
c. Ask the patient to turn to one side. Percuss
the abdomen from the bed upward. Note
change of sound from dull to tympanic. Mark
the area.
26. End of the Examination
b. Assists patient in dressing up
c. Says Thank You
TOTAL
SCORE
0.25
0.5
0.5
1.0
1.0
2.0
1.0
2.0
0
0
0
0
0.5
0.5
0.5
0.5
1.0
1.0
1.0
1.0
Guide in Rating
95 100
EXCELLENT
90 94
VERY GOOD
85 89
GOOD
80 84
SATISFACTORY
75 79
FAIR

be practiced
___________________________
Clinical Instructor

COLLEGE OF NURSING
ASSESSING THE MUSCULOSKELETAL SYSTEM
NAME _______________________________
________
Preparation
100
points
Goniometer
Procedure
1. Introduce yourself, and verify the patients
identity. Explain to the patient what you are
going to do, why it is necessary, and how
the patient can cooperate.
2. Perform hand hygiene, and observe other
appropriate infection control procedures.
4. Inquire if the patient has any history of the
following:
Muscle pain: onset, location,
character, associated phenomena,
and aggravating and alleviating
factors
Any limitations to movement or
inability to perform activities of daily
living
Previous sports injuries
Any loss of function without pain
Assessment
Muscles
5. Inspect the muscles for size.
Compare each muscle on one side of the
body to the same muscle on the other
side. For any apparent discrepancies,
measure the muscles with a tape.
6. Inspect the muscles and tendons for
contractures.
7. Inspect the muscles for tremors.
Inspect any tremors of the hands and
arms by having the patient hold arms out
in front of body.
8. Palpate muscles at rest to determine muscle
tonicity.
9. Palpate muscles while the patient is active
and passive for flaccidity, spasticity, and
smoothness of movement.
10. Test muscle strength. Compare the right side
with the left side.
a. Test flexion and extension at the elbow.
Have the patient pull and push against
your hand
b. Test extension at the wrist.
Ask the patient to make a fist and resist
your pulling it down.
c. Test the grip
> Place you middle finger on top of
Year & Section
Not
Done
Done
Done
Incorrectly Correctly
0.5
1.0
0.5
1.0
0.5
1.0
1.0
2.0
1.0
2.0
1.0
2.0
1.0
2.0
1.0
2.0
1.5
3.0
1.5
3.0
1.5
3.0
1.5
3.0
Remarks
d.
e.
f.
g.
h.
i.
j.
k.
l.
your index finger.

> Ask the patient to squeeze two of
your fingers as hard as possible and
then let them go.
Test finger abduction
> Position the patients hand with palm
down and fingers spread.
> Instruct the patient not to let you
move the fingers, try to force them
together.
Test opposition of the thumb
Ask the patient to touch the tip of the
little finger with the thumb, with the
thumb against your resistance.
Test flexion of the hip
> Place your hand on the patients
thigh
> Ask the patient to raise the leg
against your resistance.
Test adduction at the hips
> Place your hands firmly on the bed
between the patients knees.
> Ask the patient to bring both legs
together against your hands.
Test abduction at the hips
> Place your hands firmly on the bed
outside the patients knees.
> Ask the patient to spread both legs
against your hands.
Test extension at the hips
> Have the patient push the posterior
thigh down against your hand.
Test extension at the knee
> Support the knee in flexion
> Ask the patient to straighten the leg
against your hand.
Test flexion at the knee
> Place the patients leg so that the
knee is flexed with the foot resting on the
bed.
> Tell the patient to keep the foot
down as you try to straighten the leg.
Test dorsiflexion and plantar flexion at
the ankle.
> Ask the patient to pull up and push
down foot against resistance.
Identify level of muscle function
1.5
3.0
1.5
3.0
1.5
3.0
1.5
3.0
1.5
3.0
1.5
3.0
1.5
3.0
1.5
3.0
1.5
3.0
m.
0
2.5
5.0
Bones
11. Inspect the skeleton for normal structure and
0
1.0
2.0
deformities.
12. Palpate the bones to locate any areas of
0
1.0
2.0
edema or tenderness.
Joints
13. Inspect the joint for swelling.
Palpate each joint for tenderness,
0
1.0
2.0
smoothness of movements, swelling,
crepitation, and presence of nodules.
14. Assess joint range of motion.
Ask the patient to move selected body parts. If available, use a goniometer to measure the
angle of the joint in degrees.
a. neck
1.5
3.0
b. shoulder
1.5
3.0
c. elbow
1.5
3.0
d. wrist
1.5
3.0
e. hip
1.5
3.0
f. knee
1.5
3.0
g. ankle
1.5
3.0
h. State significance of findings
0.5
1.0
2.5
5.0
2.5
5.0
0.5
1.0
0
0
0
0
0.5
0.5
0.5
0.5
1.0
1.0
1.0
1.0
SPECIAL TECHNIQUES
1. Phalens Test
> Ask the patient to press the backs of
both hands together to form right angles
2. Tinels Sign
> With your finger, percuss lightly over
the course of the median nerve in the
carpal tunnel.
3. State significance of findings
15. End of the Examination
c. Says Thank You
TOTAL
SCORE
Guide in Rating
95 100
EXCELLENT
90 94
VERY GOOD
85 89
GOOD
80 84
SATISFACTORY
75 79
FAIR

be practiced
___________________________
Clinical Instructor

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Checklist for Patient Interview

1. Nurse must collect background information from previous charts.

Able to execute the procedure without mistake; observes the

Checklist for Patients Admission and Discharge

Welcomes patient to the unit

Able to execute the procedure without mistake; observes the basic

UNIVERSITY OF SANTO TOMAS COLLEGE OF NURSING

Year & Section_____

ASSESSING THE THORAX and LUNGS

1. Identify patients identity and introduce yourself. Explain to the

d. Place your nondominant hand on the surface of the body with

Able to execute the procedure without mistake. Observes the basic

UNIVERSITY OF SANTO TOMAS

Year & Section ______________

9. Ending the Examination

UNIVERSITY OF SANTO TOMAS

Year & Section ______________

b. Release the pressure

b. Note the characteristics of peripheral pulses.

b. Dorsiflex the foot with the other hand

UNIVERSITY OF SANTO TOMAS

Year & Section ___________

14. Cranial Nerve II Optic

1.2. Test for distant vision position patient 20 feet from

16.2 Test for sensory function

heard by bone conduction versus air

22. Biceps Reflex

a. Rest the patients arm on your forearm or on

28. Plantar (Babinskis) Reflex

also use a sitting position for this test.

33. Light-Touch Sensation

simultaneously touch a finger pad in two

Able to execute the procedure without mistake observing the basic

UNIVERSITY OF SANTO TOMAS

Year & Section __________

abdomen and measure at the level of the

a. Place left hand under the lower portion of the

with your other hand.

Able to execute the procedure without mistake observing the basic

UNIVERSITY OF SANTO TOMAS

Year & Section

your index finger.

h. State significance of findings

Able to execute the procedure without mistake observing the basic

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