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. 

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.

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. Document that skin is intact, clear, free from lesions, 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. Inspect throughout hair.

2. Check texture, hair distribution, and color.

3. Inspect the skin for lesions and tenderness.

4. Check the size and shape of scalp.

5. Document if scalp is “normocephalic.”

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, EOM and PERRLA intact, and peripheral vision intact. 

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 and not tender. Hearing intact.

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. Document that mucosa is pink and without drainage, that nostrils are clear for breathing (nares patent). 

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 shrug shoulders, roll shoulders.

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

6. Check resistance of the neck. 

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

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. 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 capillary refill of toenails.

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

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

5. Document strength of FROM (+5), strength of pulse (+2), capillary refill speed (< 3 sec.) bilaterally. Sensation intact. 

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 rotate wrists.

5. 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. 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).