Health Assessments Skills Checklist

Washing Hands

1. Remove watches and rings.

2. Stand in front of sink, avoiding touching the sink with uniform.

3. Turn on water. Ensure that water is warm, and avoid splashing.

4. Wet hands and wrists, keeping forearms low.

5. Rub 3-5 mL of soap on hands for at least 20 seconds.

6. Clean under fingernails, nails, backs of hands, palms, and wrists.

7. Dry hands from wrists to forearms until completely dry.

8. Discard paper towel. Use a new paper towel to turn off faucet, if needed.

Donning PPE

1. Wash hands.

2. Gather equipment.

3. Apply gown and tie securely in the back.

4. Put on surgical mask or respirator.

5. Put on goggles or face-shield if using glasses.

6. Apply clean gloves over gown cuff.

7. Enter patient room.

Doffing PPE

1. Remove PPE inside patient’s room.

2. Remove gloves by pulling the cuff with your opposite hand, balling up the glove, and pulling the last glove from underneath the other cuff. 

3. Remove goggles, but keep on face shields. 

4. Remove gown, turning it inside out and rolling it into hands.

5. Remove mask. 

6. Perform hand hygiene (if patient has C. diff, wash hands with soap and water).

Tympanic Temperature

1. Cover the tip of the thermometer with a disposable cover.

2. Pull the ear back, up, and out. 

3. Insert the probe into the ear canal. 

4. Press the scan button.

5. Wait until the temperature has been read.

Apical or Radial Pulse

1. Review chart for baseline pulse.

2. Place exam bed at 45-60* angle.

3. Locate the apical pulse in the 5th intercostal space.

4. Place the diaphragm on the apical pulse location.

5. If heartrate is regular, count for 30 seconds and multiply by two. If irregular, count for the full minute.

6. Inform patient of results.

Blood Pressure

1. Place the patient’s arm at heart level. 

2. Expose the upper arm and locate the brachial pulse.

3. Place appropriately-sized cuff on patient. 

4. Turn the pressure all the way down on the sphygmomanometer.

5. After placing the diaphragm, inflate the cuff until the pulse is no longer felt. 

6. Count the number where the first heartbeat is heard, and count the number where the last heartbeat is heard.

7. Slowly release pressure on valve.

8. Record the systolic and diastolic readings. 

Entering the Patient Care Area

Perform these steps before every skill.

1. Gather equipment.

2. Perform hand hygiene, and if touching foreign objects, wash again before touching the patient.

3. Introduce yourself.

4. Identify the patient using the three identifiers.

5. Explain the procedure (AIDET).

General Survey

1. Weigh the patient (kg and lbs).

2. Measure the patient’s height.

3. Note posture and gait.

4. Assess for gross deformities.

5. Identify assistive medical devices used by patient.

6. Apparent age.

7. Appearance (hygiene/grooming, clothing choices, scent).

8. Level of consciousness (alertness and orientation level).

9. Note signs of distress in behavior or demeanor (and mood).

10. Note speech patterns.

11. Record nutritional status. 

12. Document that patient appears stated age and is pleasant. Well groomed, well nourished. Appropriate affect and speech. Gait is balanced, posture erect. No gross deformities or apparent distress.

Mental Screening

1. Ask the patient if they know their name (Alert to Self).

2. Ask the patient if they know where they are (Alert to Place). 

3. Ask the patient the day of the week or year (Alert to Time).

4. Ask the patient if they know why they’re at the hospital (Alert to Situation). 

_{These previous four questions will allow you to document if the patient is alert and oriented (A&O x1-4).}

5. Ask the patient if they remember something recent and what they did during a holiday or birthday in the past.

6. Ask patient to touch finger to nose.

7. Document that patient is A&Ox4, short and long term memory intact.

Skin Check (Bodily)

1. Observe skin for color and lesions.

2. Palpate skin in each major bodily area.

3. Note the temperature, texture, and stretch (turgor) of the skin.

4. Do light touch and sharp touch throughout extremities.

5. Check nails for color, symmetry, or damage.

6. Document that skin is intact, clear, free from lesions, responsive to stimuli, warm, and not tender.

HEENT Steps (Sitting)

1. Check the head.

2. Check the face.

3. Check the eyes.

4. Check the ears.

5. Check the nose. 

6. Check the mouth.

7. Check the neck.

Head Examination

1. Note head shape.

2. Check skin throughout hair.

3. Check texture, hair distribution, and color.

4. Inspect the skin for lesions and tenderness.

5. Check the size and shape of scalp.

6. Document if scalp is “normocephalic.” Nontender, with no hair loss.

Face Examination

1. Look at the face and note symmetry.

2. Palpate the face. Ask the patient to clench their jaw as you feel the temporal and masseter muscles. 

3. Use a cotton ball to sense light touch. Use an unopened alcohol pad to assess sharp touch. 

4. Ask the patient to smile and frown.

5. Document that face is symmetrical, sensation is intact, and facial movement is intact.

Eye Examination

1. Inspect the conjunctiva, or whites of eyes.

2. Inspect the sclera by pulling down on lower lid and indicating that area is pink and free of discharge.

3. Ask the patient if they can read something close, and then something far.

4. Ask the patient to hold head still and follow the penlight. Bring penlight to patient’s nose, and then bring it back. While still holding head still, bring penlight diagonally and side-to-side.

5. Ask patient to hold their hand over their eye, and the nurse will put their hand on their own eye. Check peripheral vision on both sides by asking patient to count the numbers you display.

6. Turn off lights and use penlight to check pupillary reflexes.

7. Document that there is no discharge, clear vision, no signs of jaundice, EOM and PERRLA intact, and peripheral vision intact. Vision is clear near and far sighted.

Ear Assessment

1. Inspect and palpate the ears for tenderness and discharge.

2. Perform whisper test by closing one ear and whispering a word at a distance to the other ear. Ask the patient if they can repeat the word.

3. Document that ears are clear, not tender, no drainage. Hearing intact at normal volume.

Nose Assessment

1. Inspect the nose. Use penlight to look into nasal mucosa.

2. Instruct the patient to close their eyes and smell an alcohol pad. 

3. Tell the patient to sniff through one nostril at a time.

4. Document that mucosa is pink and without drainage, that nostrils are clear for breathing. 

Mouth Assessment

1. Inspect lips. Grab a tongue depressor and check gums, cheeks, under tongue, and uvula (while patient makes an “ahh” sound).

2. Ask the patient to swallow.

3. Ask the patient to move their tongue up-and-down to check movement.

4. Instruct the patient to verbalize the phrase: “Light, tight, dynamite!”

5. Document that areas of mouth are pink and without lesions. Uvula is responsive and symmetrical. Tongue is mobile and symmetrical. Vocalization intact. No difficulty swallowing.

Neck Assessment

1. Inspect the area for intact skin.

2. Palpate the trachea, or around the middle of the neck. 

3. Palpate carotid arteries on each side, independently. 

4. Ask patient to look to the side bilaterally to check for jugular vein distension.

5. Ask patient to shrug shoulders, roll shoulders.

6. Have patient move head up-and-down, side-to-side.

7. Check resistance of the neck. 

8. Document that trachea is aligned (midline). Carotid artery (+2), bilaterally. Indicate full range-of-motion (FROM), assess strength bilaterally (+5).

Arm, Hand, and Nail Assessment

1. Inspect down arms, including observing skin, soft and sharp touch, and palpate for temperature and texture.

2. Pinch the skin at the hand to inspect turgor and skin tenting.

3. Press finger down on capillaries to check refill time.

4. Assess clubbing by checking for the “diamond.”

5. Check around individual joints, radial and brachial pulse, and sensation in hand. 

6. After brachial pulse, palpate for the tendon and test deep tendon reflexes.

7. Ask the patient to squeeze fingers as hard as they can.

8. Document skin condition. Capillary refill time (<3 sec), bilaterally. No clubbing. No joint deformities, nontender. Full range-of-motion (FROM). Bilateral Upper Extremeties (BME) pulses (brachial +2, radial +2). Deep Tendon Reflexes (DTE) (bicep +2). BUE sensation intact to light and dull touch.  

Foot Assessment

1. Inspect down feet to ensure there is no swelling, lesions, or abnormal skin color. Note hair distribution.

2. Check skin turgor of legs.

3. Check capillary refill of toenails.

4. Palpate the arteries from the top of the foot (dorsalis pedis) and under the ankle bone (posterior tibial).

5. Test light and dull sensation using a cotton ball and the end of an alcohol pad. 

6. Check reflexes in the knee and the Achilles. 

7. Document strength of FROM (+5), strength of BLE pulse (+2), capillary refill speed (< 3 sec.) bilaterally. Sensation intact for sharp and dull touch. 

Range of Motion Exercises (Upper Body)

1. Check neck rotation. Ask patient to hold neck position with resistance on each side.

2. Ask patient to shrug shoulders, rotate. Ask patient to hold shoulder position with resistance on each side.

3. Instruct patient to hold up arms and hold position with resistance from front and back, and side-to-side.

4. Ask patient to hold up hands, and press patient back. Then pull their hands from behind.

5. Instruct the patient to rotate their wrists.

6. Ask patient to squeeze nurses’ fingers as hard as comfortable.

Range of Motion Exercises (Lower Body)

1. While still sitting, instruct patient to do extension of knees. Ask patient to hold knee position with resistance on each side. 

2. Move to feet. Instruct patient to rotate ankles and flex feet up and down. Ask patient to hold foot position with resistance from under the foot. 

3. While standing, ask the patient to bend over and instruct them that you will check their spine alignment. 

4. Ask patient to rotate hips in circular motion.

5. Instruct the patient to touch their heels to their shin area.

6. Document FROM bilaterally from each area (+5).

Deep Tendon Reflex

1. Obtain tendon hammer.

2. Palpate the tendon in the lower bicep and strike quickly with tendon hammer. If you cannot feel it, ask the patient to flex.

3. Palpate the tendon in the tricep area and strike quickly with tendon hammer. If you cannot feel it, ask patient to completely straighten arm.

4. Palpate the tendon in the radial hand area and strike quickly with tendon hammer.

5. Palpate the tendon under the patella of the knee and strike quickly with tendon hammer.

6. Palpate the tendon in the achilles’ heel area and strike quickly with tendon hammer. Place hand towards the front of the foot and ensure that ankle is straight.

7. Document successful deep tendon reflexes (+2). 

Gait

1. Ask patient to stand with feet together and arms out with eyes closed.

2. Ask patient to stand still with eyes closed for at least 20 seconds. 

3. Ask patient to walk to the other side of the room, walk heel-to-toe, walk on heels, and walk on tiptoes. 

4. Document that gait is even and smooth, coordination and balance intact.

Cardiovascular

1. Inspect and palpate precordium for pulses (PMI is the apex of the heart, strongest point).

2. Check each intercostal space (2nd bilaterally, 3rd, 4th, 5th under nipple line) with diaphragm and bell of stethoscope. 

3. Check the carotid arteries with bell of stethoscope. 

4. Document that heart rhythm is regular, no extra sounds heard. No heaves or thrills. Heart sounds clear (S1 and S2, “lub-dub”). PMI at 5th intercostal space,

Respiratory

1. Assess breathing rate, pattern, and use of accessory muscles.

2. Inspect A/P diameter by checking with hands on waist, and then measuring a 1:2 ratio.

3. Ask the patient to turn around, and while pinching between the skin between the spine, ask the patient to breathe in and breathe out, following their movement with your hands. 

4. Listen towards the anterior and posterior regions of the body for lung sounds, from 6 to 8 fields. For the last two fields, move the diaphragm towards the side of the body, closer to the waist. 

5. Document that respirations are regular and unlabored. Lungs are clear to auscultation. No adventitious sounds. AP:Transverse ratio is 1:2. Chest expansion equal bilaterally.

Abdominal

1. Observe skin contour, symmetry, and movements.

2. Note the shape of the abdomen.

3. Recognize that the bellybutton is midline.

4. Place diaphragm from the RLQ clockwise and check for bowel sounds.

5. Lightly palpate the four quadrants for tenderness, distension, etc.

6. Document abdomen flat. Umbilicus midline. No visible pulses or peristalsis. BT present in 4 quads. No tenderness with palpation.

Medication Administration

For final assessment, document in MAR the date of testing. Put initials. 

1. Wash Hands

2. Check allergy list: Sulfa, Codeine, Bee Stings. 

3. Verify medications 3 times. Refer to: Mr. Garand chart first compared to MAR, then MAR at cart after removing medication, and once at bedside. 

   1. Ensure that medication is not expired. 

   2. Verbalize medication, dose, time while checking for medications. 

   3. Place pills in a paper cup, place liquids in a plastic cup. Fill the water cup and provide a straw. 

4. Ask the patient their name, and ask again. Confirm allergies with patient. Scan armband if applicable. 

5. Explain to the patient the process of giving medications and why you're giving it, tell side effects. “If you experience these symptoms, please let me know!”

   1. Lanoxin causes GI symptoms and heart rhythm abnormalities.

   2. Lasix causes dehydration and electrolyte imbalance.

   3. Metformin causes GI symptoms with rare lactic acidosis.

   4. Warfarin causes GI symptoms and abnormal bleeding.

   5. Potassium Chloride causes muscle, CNS, and heart rhythm abnormalities.

   6. Atorvastatin causes GI and muscle spasms.

   7. Amoxicillin causes abnormal bleeding and allergic reactions.

   8. Albuterol causes thrush, tremors, and tachycardia.

   9. Morphine causes respiratory distress and dependence.

6. Prior to giving medication, do pre-assessment. 

   1. Exp. Lanoxin needs to check the pulse for 60 seconds. “If the apical pulse is less than 60, I cannot give the medication.” 

   2. For Lasix, check potassium level.

   3. For Metformin, check blood glucose.

   4. For Warfarin, check INR. 

   5. For Potassium Chloride, check potassium levels.

   6. For Atorvastatin, check the cholesterol level (LP: 256 chol).

   7. For Amoxicillin, double-check allergies. 

   8. For Albuterol, check respirations and pulse.

   9. For Morphine, check pain level.

   10. Raise head of bed, as medications cannot be administered lying down.

   11. Scanning medication needs to be done as the third check for medications. 

7. “Are you able to take two medications at a time, or would you prefer one-by-one?” 

   1. Do not actually open the medications, as they are reusable. Place it back in its right spot. 

8. “I will check with you in 30 minutes to see how you are doing. Do you have any questions? Are you comfortable in this position? I will give you your call light.”

   1. Re-state the medication side effects.

9. Wash hands again, making sure the patient’s bed is down and locked.