BSCN 2020 Lab Manual W2024

BSCN 2020
BRIDGING HEALTH
ASSESSMENT
LAB MANUAL
2023-2024
BScN 2020 Health Assessment_W2024 Page 1 of 73

WELCOME TO HEALTH ASSESSMENT
THE LAB COMPONENT OF HEALTH ASSESSMENT IS A HYBRID DESIGN, INCLUSIVE OF
WEEKLY STUDENT INDEPENDENT LEARNING AND LAB SESSIONS.
LAB SESSIONS
Lab sessions will help students apply and consolidate knowledge from the weekly learning
materials posted on Blackboard. Students are required to be self-directed in completing all online
activities, required readings, videos and other online components posted on the course blackboard
site. The on-line work is to be completed each week, independently, in preparation for the lab
session. It is an expectation that students attend all lab sessions.
WEEKLY LABS
Weekly lab sessions are comprised of the following:
− Student independent preparation

− Lab session (on campus in labs)
− Student independent practice
DRESS CODE, CODE OF CONDUCT, ATTENDANCE AND PARTICIPATION

− The Humber College uniform must always be worn during lab, including the mini and final
practicum.
− Students are also responsible for acting in a manner that respects others and promotes their
well-being and safety.
− Please refer to the UNB/Humber Student Handbook (2023-2024) for additional information on
the Student Uniform and Code of Conduct Policies.
− Students are expected to have completed the weekly required readings, viewed the assigned
video(s), prior to the weekly lab class. Students also are expected to come to lab with applicable
lab kit materials and dress attire appropriate for the role of patient in order to fully participate
in examination/assessment techniques of the system/activity for that week.
REQUIRED RESOURCES
Astle, B.J., & Duggleby, W. (2024). Canadian fundamentals of nursing (7th ed.). Elsevier Canada.
Jarvis, C., Browne, A. J., MacDonald-Jenkins, J., & Luctkar-Flude, M (2024). Physical
examination and health assessment (4th ed.). Elsevier Canada.
RECOMMENDED RESOURCES
Jarvis, C., Browne, A. J., MacDonald-Jenkins, J., & Luctkar-Flude, M (2024). Pocket companion
of physical examination and health assessment (4th ed.). Elsevier
Elsevier (2023) Canadian Clinical Skills: Essentials Collection - eCommerce Version.

SCHEDULE FOR WEEKLY TOPICS / ACTIVITIES
WEEK 1
− Overview of lab expectations
− Professional and Essential Behaviours
− Interviewing
− The Complete Health History
WEEK 2
− Communication and − General Survey

Documentation Worksheets − Measurements
− Vital Signs
WEEK 3
− Vital Signs continued − Assessment Techniques (IPPA)
− Symptom and Pain Assessment
WEEK 4
− Thorax and Lungs Assessment
WEEK 5
− Heart and Neck Vessels Assessment
− Peripheral Vascular System Assessment
WEEK 6
− Mini Practicum
WEEK 7
− Head, Face, and Neck Assessment
− Regional Lymphatic System Assessment
− Eyes Assessment
− Ears Assessment
− Nose, Mouth, and Throat Assessment
− Practice for Mini Practicum
WEEK 8
− Skin/Hair/Nails Assessment
− Client Teaching: Self-Examination
− Braden Scale
WEEK 9
− Musculo-Skeletal Assessment

WEEK 10
− Neurological Assessment
− Mental Health Assessment
− Montreal Cognitive Assessment – Basic (MoCA-B)
− Glasgow Coma Scale
WEEK 11
− Abdominal Assessment
− Nutritional Assessment - Nutrition Lab Worksheet
WEEK 12
− Breast and Axillae Assessment
− Male/Female Genitalia
− Complete Health Assessment
− Focused Assessment
− Practice for Final Practicum
WEEK 13
− Final Practicum

WEEKLY LAB WORKSHEETS: STUDENT PERFORMANCE CHECKLISTS
PLEASE NOTE:
IN LABS, STUDENTS MUST COMPLETE THE FOLLOWING ACTIONS TO RECEIVED FULL MARKS, IN THE
RESPECTIVE SECTIONS:
− All Professional and Essential Behaviours (infection control, professionalism, interview)

− Verbalize actual, expected and normal findings for all IPPA components.
PHYSICAL EXAM AND HEALTH ASSESSMENT:
PROFESSIONAL AND ESSENTIAL BEHAVIOURS
Infection Control Yes No Comments
Washes hands
Use of personal protective equipment as needed

Professionalism Yes No Comments
Patient identifiers (two)
Explains health history and physical exam procedure
Provides privacy
Ensures confidentiality
Gathers equipment
Demonstrates professional conduct when
interviewing a client for a health history and
performing a physical examination
Conducts a focused, systematic, accurate and

timely health history and physical examination
Dressed according to Humber College uniform policy

INTERVIEW YES NO COMMENTS
Create an appropriate physical environment
Provide privacy
Greet client by proper name
Introduce self
Refuse interruptions
Wear appropriate attire
Provide a clear introduction to the interview
State the time available for the interview
State the purpose of the interview
Indicate the role of each participant
If an adolescent or adult, ask permission from

client for other health care providers or
family members to be present
Indicate confidentiality of the interview and

any limitations
Use verbal responses appropriately (see nine

types listed in the textbook)
Use appropriate non-verbal behaviour
Respond appropriately to client’s non-

verbal behavior
Provide the client time to respond
Use appropriate terminology/language
Close the interview with a summary of the

information discussed.
Uses polite signal that the interview is complete
Consider special needs of the client
Adapted from:
JARVIS, C. (CURRENT EDITION). PHYSICAL EXAMINATION AND HEALTH ASSESSMENT. (CURRENT ED.). TORONTO, ON: ELSEVIER.

WEEK ONE: THE COMPLETE HEALTH HISTORY
Name: Lab Section:
Teacher: Date:____________________________________
BIOGRAPHICAL DATA (SOURCE OF HISTORY)
REASON FOR SEEKING CARE
CURRENT HEALTH OR HISTORY OF CURRENT ILLNESS (SYMPTOM ANALYSIS)
O Onset
P Provocative/Palliative
Q Quality/Quantity
R Region/Radiation
S Severity Scale
T Treatment/Timing
U Understanding/
client’s Perception
V Values

PAST HEALTH HISTORY
Childhood Illnesses
Accidents or Injury
Serious or Chronic
Illnesses
Hospitalizations
Operations
Obstetrical History
Immunizations
Most Recent Examination

Date
Allergies
Current Medications
(OTC and Prescription,
Herbal Remedies)
FAMILY HISTORY
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________

REVIEW OF SYSTEMS
System Review
General Overall Health State
Skin/Hair/Nails
Head, Eyes, Ears,

Nose/Sinuses, Mouth/Throat,
Neck
Breast, Axilla
Respiratory
Cardiovascular
Peripheral Vascular
Gastro-intestinal
Genitourinary
Musculoskeletal
Sexual Health
Neurological
Hematological
Endocrine

FUNCTIONAL ASSESSMENT (INCLUDING ACTIVITIES OF DAILY LIVING)
Self-Concept,
Self -Esteem
Activity and
Mobility
Sleep and Rest
Nutrition and
Elimination
Interpersonal
Relationships and
Resources
Spiritual
Resources
Coping and Stress

Management
Tobacco Use
History
Alcohol
Substance Use
Environmental
Hazards
Intimate
Partner
Violence
Occupational
Health

PERCEPTION OF OWN HEALTH
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________

WEEK TWO AND THREE: GENERAL SURVEY, MEASUREMENT, VITAL SIGNS ,
COMMUNICATION AND DOCUMENTATION
GENERAL SURVEY
PHYSICAL APPEARANCE
Age (appears their stated age)
Sex (sexual development consistent with gender & age)
Level of Consciousness (state the correct LOC based on assessment)
Skin Colour (consistent with ethnic background, skin intact no lesions)
Facial Features (symmetrical)
BODY STRUCTURE
Stature (height)
Nutrition (weight)
Symmetry (bilaterally)
Posture (erect)
Position (sitting, standing, laying, examination table-comfortable)
Body Build/Contour [(a) arm span (fingertip to fingertip) equals height; (b) body length from crown
to pubis approximately equal to length from pubis to sole]

MOBILITY
Gait (base width equal to shoulder width; accurate foot placement; smooth, even, & well-balanced
walk; & presence of associated movements)
Range of Motion (full mobility, smooth movement)
BEHAVIOUR
Facial Expression (eye contact—unless culturally not appropriate, expressions appropriate to
circumstances)
Mood & Affect (comfortable, cooperative)
Speech (clear articulation, clear, fluent)
Dress (appropriate to climate, clean)
Personal Hygiene (clean, groomed)

MEASUREMENTS
Weight (kilograms)
Height (centimetres)
Body Mass Index (what does it measure, how do you calculate it, how do you use the Nomogram)
BMI = Weight (kilograms)

Height (metres)2
CALCULATE, GRAPH, AND INTERPRET THE FOLLOWING FINDINGS.
a) 16-year-old male client weight = 180 pounds, height = 5 feet 7 inches
b) 14-year-old female client weight = 40 kg, height = 1.65 metres
c) 86-year-old male client weight = 150 pounds, height = 69 inches
d) 42-year-old female client weight = 50 kg, height = 5 feet 4 inches

VITAL SIGNS CHECKLIST (PERFORMANCE AND FINDINGS)
ASSESSMENT OF MARK OUT

PROCEDURE COMMENTS
VITAL SIGNS OF
Temperature Demonstrates correct 2

technique
Accurately reports route &

findings
Pulse Demonstrates correct 2

technique
Rate, Rhythm, Force
(scale: 3+ to 0) & reports

findings
Respirations Demonstrates correct technique 2
Rate, Rhythm, Effort, Depth

Accessory Muscle Use & reports
findings
Blood Pressure Demonstrates correct technique 2

Pre-determined Blood Pressure
Measurement & reports findings
O2 Saturation Demonstrates correct technique 2
Accurately reports findings
TOTAL 10

SYMPTOM AND PAIN ASSESSMENT
DESCRIPTION OF SYMPTOM
MNEMONIC - OPQRSTUV RESPONSE
O (Onset)
P (provocative/palliative)
Q (quality/quantity)
R (region/radiation)
S (severity scale)
T (treatment/timing)
U (understanding/ client’s
perception)
V (Values)

DOCUMENTATION WORKSHEET
COMPLETE THE CONVERSION OF THE STANDARD TIME TO 24-HOUR CLOCK TIMING.
CONVERSION TO MILITARY TIME

Activity Standard Time Military Time
Administration of insulin 6:00 pm
Dressing change 10:00 am
Breakfast served 7:30
8:00 am
pm
Interprofessional Rounds 11:15 am
Evening shift start and finish time 3:00 pm
Intravenous bag change due 12:30
11:00 pm
Transport client to operating room 4:20 pm
Client received from the emergency department 3:08 am
Nightshift report 12:05 pm

Chest physio 6:00 am
1:00 pm
5:00 pm
10:00 pm

DOCUMENTATION WORKSHEET
THE CLIENT RECORD IS AN IMPORTANT SOURCE OF INFORMATION. THE PURPOSES OF

DOCUMENTING ASSESSMENT FINDINGS INCLUDE:
− Communication and care planning

− Legal documentation
− Education
− Funding and resource management
− Research
− Auditing-monitoring.
TYPES OF CHARTING
SUBJECTIVE–OBJECTIVE–ASSESSMENT–PLAN – INTERVENTION – EVALUATION (SOAPIE)

− subjective data (verbalizations of the client)
− objective data (data that are measured and observed)
− assessment (diagnosis based on the data)
− plan (what the caregiver plans to do)
− Intervention (what the interventions are based on the plan)
− Evaluation (evaluates the outcome(s) for each intervention)
DATA-ACTION-RESPONSE (DAR)
− data (subjective and objective data—not only problem—can be issue, behaviour)
− action (nursing actions and interventions)
− response (evaluation of nursing actions or interventions)

CASE SCENARIOS:
SCENARIO #1
Claire Diane, an 18-year-old female (DOB 03/22/2001) arrived in the emergency room at 8:15 pm
with a swollen left ankle after twisting it when playing ultimate frisbee with her friends. Her
temperature on admission is 36.7 C PO. She rates the pain in her foot 8 out of 10 on a scale of 0=no
pain to 10=worst pain she has ever felt. Her boyfriend and her coach brought her into the hospital.
Her pulse is 88 beats per minute. She gives her mother’s name Evette Deon as the next of kin.
Claire’s ankle is swollen and beginning to discolour to a purplish blue. Her respirations are 14 per
minute. She is alert and responding appropriately to questions but she seems to be in extreme pain
and appears distressed. Claire tells you she feels a terrible throbbing in her foot. She is not able to
move her affected foot nor can she weight bare. Her BP is 130/72. Claire is wearing a medic alert
bracelet and is allergic to latex. She is 5 feet 4 inches and reports that she weighs 118 pounds. She
has seen the emergency room physician Dr. Lemaire and is scheduled for an X-ray of the ankle and
a consultation with the orthopedic surgeon on call.
SCENARIO #2
Hasan is a 3-year-old who is being seen at the medical walk-in clinic. His mother Mariam tells you
that her son has been vomiting for 3 days, but has had no diarrhea. Hasan looks pale, tired, and is
clinging to his mother.
His blood pressure is BP 86/62. He points to the sad face on the Faces Pain Scale. It is unclear where
Hasan’s pain is but Mariam says that Hasan keeps repeating the Arabic word for tummy. Mariam
reports that Mariam has not had anything to eat or drink for 24 hours and before that was only taking
sips of fluids. Hasan’s temperature is 40.0 C T Mariam tells you that no one else is sick in the house,
nor is anyone sick at Hasan’s daycare. Mariam mother tells you Hasan’s last weight was 32 pounds.
Today Hasan weighs 12 kg. Hasan’s pulse is 158 beats per minute (apical), respirations 39/minute,
and oxygen saturation 90% (on room air). Hasan has become increasingly lethargic throughout the
day, causing Mariam to become concerned and bring him to the clinic. Hasan has been seen by Dr.
Patel and a pediatrician has been consulted. An IV of Normal Saline has been ordered to be started
on Hasan, along with blood cultures. The IV nurse has been called.
LIST THE OBJECTIVE DATA FOR EACH OF THE SCENARIOS.
LIST THE SUBJECTIVE DATA FOR EACH OF THE SCENARIOS.

DOCUMENT ONE THE OF ABOVE SCENARIOS USING SOAPIE AND THE OTHER USING DAR
DOCUMENTATION FORMAT.
HUMBER GENERAL HOSPITAL
Nursing Documentation of Assessment Findings SOAPIE Documentation
HUMBER GENERAL HOSPITAL
Nursing Documentation of Assessment Findings DAR Documentation

CHART THE VITAL SIGNS FOR EACH CLIENT.
VITAL SIGN RECORD
Client Name:
Physician Name:
Date of Birth:
Emergency Contact:
Date Temp Pulse Resp BP Pain O2 Sat Weight

VITAL SIGN RECORD
Client Name:
Physician Name:
Date of Birth:
Emergency Contact:
Date Temp Pulse Resp BP Pain O2 Sat Weight

SBAR SHIFT →SHIFT REPORT
This form is to assist in performing complete, precise patient hand off from shift to shift.
Situation
Patient Name: ____________________________ Room:_____ Age:_____ Sex:_____
Level of Care: _____________________________
Physician: ________________________________
Admitted from: ___________________________ (home, nursing home, assisted living, etc.)
Background
Admission Diagnosis: _______________________
Date of Surgery (if applicable): _____________________________________
Pertinent past medical history: ______________________________________________
(hypertension, CHF, etc.)
Assessment
Code Status: _______________________ (advance directives, DNR, POA for health care)
Abnormal V.S. ______________________
IV site – lock/fluids/site/drips/when to change IV site: ___________________________
Procedures done in the last 24 hours (include any known results): _________________
Abnormal Assessments: ___________________________________________________
_______________________________________________________________________
_______________________________________________________________________
Current pain score: __________________ What has been done to manage this plan:
_______________________________________________________________________
Safety needs/fall risk /skin risk, etc.: _________________________________________
Recommendation
Needed changes in the plan of care? (diet, activity, medication, consult):
_______________________________________________________________________
What are you concerned about? ____________________________________________
Discharge Planning: ______________________________________________________
Pending labs/x-rays, etc: __________________________________________________
Call out to Dr. ______________________ about _______________________________
What the next shift needs to be aware of: ____________________________________
1/2009 sg #NUR182 *Document any change in condition and physician notification on patient MR

WEEK FOUR: THORAX AND LUNGS ASSESSMENT WORKSHEETS
THORAX AND LUNGS HEALTH HISTORY MARK OUT OF COMMENTS

Determines reason for seeking care 1
O (Onset) 1
P (Palliative, Provocative) 2
Q (Quality) 1
R (Region/Radiation) 2
S (Severity Scale) 1
T (Treatment/Timing) 2
U (Understanding) 1
V (Values) 1
Cough 1
SOB 1
Chest pain with breathing 1
Smoking/vaping History (pack/day, 1

length of time, attempts to quit)
Environment Conditions or exposure 1

that affects breathing effort
Self-care Behaviours: (last TB test or skin 3
test, chest x-ray, flu shot)
Past history of Respiratory Disorders 1
(asthma, COPD)of Respiratory Disorders/
Family History 1
Problems
Medication Use (prescribed, OTC, herbal, 5
recreational drug use, supplements)
Allergies 1
TOTAL 28

PHYSICAL EXAMINATION OF THORAX AND MARK OUT OF COMMENTS
LUNGS - INSPECTION
Inspects posterior and anterior chest for: 3

− Thoracic cage (shape,
configuration & symmetry)
− Anterior-posterior diameter
− Spinous processes
Skin colour and condition 1
Body position 1
TOTAL 5
PHYSICAL EXAMINATION OF THORAX MARK OUT OF COMMENTS

AND LUNGS – PALPATION
Identifies landmarks for: 5

− suprasternal notch
− Angle of Louis (Manubriosternal Angle)
− second rib
− C-7
− T-1
Palpates posterior chest (using correct 1

technique) for lumps, masses, lesions,
and/or tenderness
Palpates posterior chest for tactile fremitus 1
Palpates posterior chest for symmetric 1

chest expansion
TOTAL 8

PHYSICAL EXAMINATION OF THORAX AND
MARK OUT OF COMMENTS
LUNGS - PERCUSSION
Percusses posterior chest in 1

correct sequence
Determines predominant note over 1

lung fields (resonance)
TOTAL 2
PHYSICAL EXAMINATION OF
THORAX AND LUNGS - MARK OUT OF COMMENTS
AUSCULTATION
Uses correct sequence and location 1

for auscultating the chest sounds
(anterior and posterior)
Uses the diaphragm of the stethoscope 1
Instructs client to breathe through the 1

mouth
Listens to full breath in each area 1

when auscultating breath sounds
Listens and identifies location for breath 3

sounds
– bronchial, broncho-vesicular, vesicular
Identify and describe any adventitious 2

breath sounds:
− Crackles
− Wheezes
TOTAL 9

WEEK FIVE: HEART AND NECK VESSELS / PERIPHERAL VASCULAR WORKSHEETS
HEART AND NECK VESSELS HEALTH HISTORY MARK OUT OF COMMENTS

O (Onset) 1
Q (Quality) 1
U (Understanding) 1
V (Values) 1
Chest pain (yes/no) if yes do OPQRSTUV 1
Dyspnea 1
Orthopnea 1
Cough 1
Fatigue and Activity Intolerance 1
Cyanosis or Pallor 1
Edema of arms, legs or feet 1
Nocturia 1
Past cardiac history 1
Family Cardiac Problems 1
Personal Habits 4
Leg pain Risk
(Cardiac or cramps
Factors e.g. smoking, diet, 1
exercise, alcohol consumption)
Skin changes on arms and legs i.e. colour, 4
enlarged veins, temperature, pain
Medications (prescribed, OTC, herbal, 5
Allergies 1
TOTAL 37

THE NECK VESSELS
AUSCULTATION
Auscultates the carotid artery for bruit 1
utilizing the bell of the stethoscope
− 3 locations – top by jaw, middle,
bottom
THE NECK VESSELS

PALPATION
Palpates the left and right carotid 1

arteries separately and describes
results
− Strength
− Equal bilaterally
TOTAL 2
THE PRECORDIUM- MARK OUT OF COMMENTS

INSPECTION AND PALPATION
Inspects the anterior chest for apical impulse 1
Palpates the apical impulse. 2

Verbalizes location and size
(1-2cm at 5th ICS at MCL)
Palpates across the precordium (apex, left 1

sternal border, base) for a pulsation in
correct order
TOTAL 4

THE PRECORDIUM MARK OUT OF COMMENTS
AUSCULTATION
Verbalizes landmarks. 3
− Landmark aortic, pulmonic,

tricuspid, & mitral valve areas and
Erb’s point.
− Auscultates four (4) auscultatory
areas – aortic, pulmonic, tricuspid, &
mitral valve with diaphragm of
stethoscope in correct order
− Auscultates four (4) auscultatory
areas – aortic, pulmonic, tricuspid, &
mitral valves with bell of
stethoscope in correct order
Identifies and verbalizes location for 2

S1 and S2
Obtains an apical pulse for rate and 1

rhythm at mitral area for 1 minute
TOTAL 6

THE PERIPHERAL VASCULAR SYSTEM
INSPECTION AND PALPATION MARK OUT OF COMMENTS
Inspects and palpates the hands and arms bilaterally
for:
− Colour
6
− Temperature (uses dorsum of hand)
− Texture
− Skin turgor
− Lesions
− Edema
Inspects / palpates nail beds bilaterally; and
describes findings for:
− Colour
− Capillary refill (1-2 seconds) 3
− Shape (profile sign)
Inspects and palpates the legs and feet bilaterally
for:
− Colour 6
− Temperature (uses dorsum of hand)
− Hair distribution
− Venous pattern
− Size (symmetry)
− Lesions or ulcers
Compares the right side to left side 1

consistently when reporting findings
Landmarks the following pulses and compares

bilaterally for symmetry and force (uses rating scale
2+ normal) at each of the following sites:
− Brachial 6
− Radial
− Femoral (verbalize only)
− Popliteal
− Posterior tibial
− Dorsalis pedis
TOTAL 22

WEEK SEVEN: HEAD, FACE, AND NECK ASSESSMENT WORKSHEETS
HEALTH HISTORY & PHYSICAL EXAMINATION – HEAD, FACE & NECK
HEALTH HISTORY – HEAD, FACE, AND NECK MARK OUT OF COMMENTS

O (Onset) 1
Q (Quality) 1
U (Understanding) 1
V (Values) 1
Headache 1
Head Injury 1
Dizziness 1
Neck Pain – limitation of motion 1
Lumps or Swelling 1
History of Head or Neck Surgery 1
TOTAL 18
PHYSICAL EXAMINATION – HEAD MARK OUT OF COMMENTS
INSPECT – HEAD
Size and Shape 2
Temporal Area (temporal artery, temporomandibular 2

joint)
TOTAL 4

PALPATE – HEAD MARK OUT OF COMMENTS
Palpate the Scalp 1
Temporal Artery 1
Temporomandibular Joint 1
TOTAL 3
PHYSICAL EXAMINATION - FACE MARK OUT OF COMMENTS
INSPECT - FACE (FACIAL STRUCTURES)

Expression 1
Symmetry 1
Edema (use scale) 1
Involuntary movements 1
Lesions 1
TOTAL 5
PALPATE – FACE MARK OUT OF COMMENTS

Edema 1
Lesions 1
TOTAL 2

PHYSICAL EXAMINATION - NECK MARK OUT OF COMMENTS
INSPECT – NECK 1
Symmetry 1
Range of Motion 1
Lymph Nodes 1
Trachea Position 1
PALPATE – NECK
Trachea Position 1
TOTAL 6

NOSE, MOUTH AND THROAT ASSESSMENT WORKSHEETS
HEALTH HISTORY & PHYSICAL EXAMINATION – NOSE, MOUTH &THROAT
HEALTH HISTORY - NOSE MARK OUT OF COMMENTS
O (Onset) 1
Q (Quality) 1
U (Understanding) 1
V (Values) 1
Discharge 1
Frequent Colds – upper respiratory infections 1
Sinus Pain 1
Trauma 1
Epistaxis 1
Allergies 1
Altered Smell 1
TOTAL 19

PHYSICAL EXAMINATION - NOSE MARK OUT OF COMMENTS
INSPECT AND PALPATE

Midline,
EXTERNAL Symmetry
NOSE 1
Deformity, Asymmetry 1
Inflammation and Lesions 1
Patency 1
TOTAL 4
NASAL CAVITY MARK OUT OF COMMENTS

Colour
Integrity (smooth, moist surface) 1
Swelling, Discharge, Bleeding, Foreign Body 1
Septum 1
− Deviation
− Perforation
− Bleeding
Turbinates 1
− Colour
− Swelling
− Polyps
PALPATE - SINUS AREA
4Pain 1
TOTAL 5

HEALTH HISTORY – MOUTH AND THROAT MARK OUT OF COMMENTS
O (Onset) 1
Q (Quality) 1
U (Understanding) 1
V (Values) 1
Discharge 1
Sores or Lesions 1
Sore Throat 1
Bleeding Gums 1
Toothache 1
Hoarseness 1
Dysphagia 1
Altered Taste 1
Smoking 1
Alcohol Consumption 1
Dentures or Appliances 1
Self-care Behaviours 1
− Dental care pattern
TOTAL 24

PHYSICAL EXAMINATION – MOUTH & THROAT MARK OUT OF COMMENTS
(USE GLOVES)
INSPECT MOUTH
Lips 1
Teeth And Gums 1
Tongue 1
Buccal Mucosa 1
Palate/Uvula 2
− Inspect
− Test cranial nerve X (ask the person to say
“ahhh”)
INSPECT THROAT
Tonsils – grade 1
Cranial Nerve XII 1

(have the patient stick out the tongue)
TOTAL 8

EYES ASSESSMENT WORKSHEETS
HEALTH HISTORY - EYES MARK OUT OF COMMENTS

O (Onset) 1
Q (Quality) 1
U (Understanding) 1
V (Values) 1
Vision Difficulty 1
Pain− Decreased acuity 1
Strabismus, Diplopia
− Blurring 2
Redness – Swelling 2
Blind spot
Watering Discharge 1
History of Ocular Problems 2
Glaucoma 1
Use of Glasses/Contact Lenses 1
Self-Care Behaviours 1
Medications
Eye check-up annually 1
Coping 1
TOTAL 25

PHYSICAL EXAMINATION - EYES MARK OUT OF COMMENTS
INSPECT – EYES
Test Central Visual Acuity 1
Test Snellen
− Visual Chart
Fields 1
Near vision
Confrontation test Function
Extraocular Muscle 1
− Diagnostic positions test
TOTAL 3
(six cardinal positions of gaze)
INSPECT EXTERNAL OCULAR STRUCTURES MARK OUT OF COMMENTS

General 1
Eyebrows 1
Eyelids and Lashes 2
Palpebral Fissures 1
Eyeball Alignment 1
Conjunctiva and Sclera 2
Lacrimal Apparatus 1
TOTAL 9

INSPECT ANTERIOR EYEBALL STRUCTURES MARK OUT OF COMMENTS
Cornea and Lens 2
Iris and Pupil 2
Size and Shape 2
PERRLA 1
Pupils Equal, Round, Reactive to Light and
Accommodation
TOTAL 7

EAR ASSESSMENT WORKSHEETS
HEALTH HISTORY - EARS MARK OUT OF COMMENTS
O (Onset) 1
Q (Quality) 1
U (Understanding) 1
V (Values) 1
Earache 1
Infections 1
Discharge 1
Hearing Loss 1
Environmental Noise 1
Tinnitus 1
Vertigo 1
Self Behaviours 3
− Hearing Assessment
− Cleaning Habits
− Hearing Aids
TOTAL 22

PHYSICAL EXAMINATION EAR MARK OUT OF COMMENTS
INSPECT – EXTERNAL EAR

Skin and Shape 2
Skin Condition 1
The External Auditory Meatus 1
TOTAL 4
INSPECT - OTOSCOPIC EXAMINATION MARK OUT OF COMMENTS

External Canal 1
Tympanic Membrane 4
− Colour
− Characteristics
− Position
− Integrity
TOTAL 5

INSPECT – HEARING ACUITY MARK OUT OF COMMENTS
Conversational speech 1
Whispered voice test 1
PALPATE – EARS –TENDERNESS

Areas: 3
− Pinna (auricle)
− Tragus
− Mastoid process
TOTAL 5

WEEK EIGHT: SKIN ASSESSMENT WORKSHEET
ASSESSMENT TECHNIQUE FINDINGS
1. INSPECT THE SKIN:

General pigmentation
Areas of hypopigmentation or hyperpigmentation
Widespread Colour Change (e.g. pallor,

erythema, cyanosis etc…)
2. PALPATE THE SKIN

Temperature
Moisture
Texture
Thickness
Edema
Mobility and turgor
Vascularity or Bruising
3. NOTE ANY LESIONS

Colour
Elevation
Pattern or Shape
Size
Location and Distribution on Body
Any Exudate: Colour and/or Odor

4. INSPECT AND PALPATE THE HAIR
Colour
Texture
Distribution
Lesions (scalp)
5. INSPECT AND PALPATE THE NAILS

Shape and Contour
Consistency
Colour
6. TEACH SKIN SELF-EXAMINATION (SEE NEXT PAGE)

TEACHING SKIN SELF-EXAMINATION (SSE)
PERFORMANCE CHECKLIST
I. COGNITIVE
1. Explain
a. Why skin is examined?
b. Who should perform skin self-examination?
c. Frequency of skin self-examination.
2. Define the ABCDE rule.
3. Describe any equipment the client may need.
II. PERFORMANCE
1. Explain the client the need for SSE.
2 Instructs client on techniques of SSE by:

a. Demonstrating the order and body
positioning for inspecting skin.
b. Describing normal skin characteristics.
c. Describing abnormal findings to look for.
3 Instruct client to report any abnormal findings to

nurse or physician as soon as possible.

BRADEN SCALE FOR PREDICTING PRESSURE SORE RISK
BRADEN SCALE - FOR PREDICTING PRESSURE SORE RISK
RISK FACTOR DESCRIPTION SCORE
SENSORY 1. COMPLETELY LIMITED

Unresponsive (does not moan, flinch, or 2. VERY LIMITED 3. SLIGHTLY LIMITED 4. NO IMPAIRMENT
PERCEPTION grasp)
Ability to respond to painful stimuli, due to diminished Responds only to painful stimuli.
Responds to verbal commands but
Responds to verbal commands.
meaningfully to cannot always communicate discomfort
level of consciousness or sedation, Cannot communicate discomfort Has no sensory deficit which
pressure-related or need to be turned, OR
OR Limited ability to feel pain over except by moaning or restlessness. would limit ability to feel or voice
discomfort most of body. OR pain or discomfort.
Has some sensory impairment which
limits ability to feel pain or
Has a sensory impairment which limits
discomfort in 1 or 2 extremities
the ability to feel pain or discomfort
over half of body
MOISTURE 1. CONSTANTLY MOIST 2. VERY MOIST 3. OCCASIONALLY MOIST 4 RARELY MOIST
Degree to which Skin is kept moist almost Skin is often but not always moist. Skin is occasionally moist, requiring an Skin is usually dry; linen only
skin is exposed to constantly by perspiration, urine, Linen/incontinent briefs must be extra linen / incontinent brief change requires changing at routine
moisture etc. Dampness is detected every changed at least once a shift. approximately once a day. intervals.
time Client is moved or turned.
ACTIVITY 1. BEDFAST 2. CHAIR FAST 3. WALKS OCCASIONALLY 4. WALKS FREQUENTLY
Degree of physical Ability to walk severely limited or Walks occasionally during day, but for Walks outside room at least twice
Confined to bed.
activity non- existent. Cannot bear own very short distances, with or without a day and inside room at least
weight and/or must be assisted into assistance. Spends majority of each once every two hours during
chair or wheelchair. shift in bed or chair. waking hours.
MOBILITY 1. COMPLETELY IMMOBILE 2. VERY LIMITED 3. SLIGHTLY LIMITED 4. NO LIMITATIONS
Ability to change Does not make even slight Makes occasional slight changes in Makes frequent though slight changes Makes major and frequent
and control body changes in body or extremity body OR extremity position but in body or extremity position changes in position without
position position without assistance unable to make frequent or significant independently. assistance.
changes independently.
NUTRITION 1. VERY POOR 2. PROBABLY INADEQUATE 3. ADEQUATE 4. EXCELLENT

RISK FACTOR DESCRIPTION SCORE
Usual food intake Never eats a complete meal. Rarely eats a complete meal and Eats over half of most meals. Eats a Eats most of every meal. Never
pattern. Rarely eats more than one-third of currently eats only about one-half of total of four servings of protein (meat, refuses a meal. Usually eats a total
any food offered. Eats two any food offered. Protein intake dairy products) each day. Occasionally of 4 or more servings of meat and
NPO: Nothing by servings or less of protein (meat or includes only three servings of meat or will refuse a meal, but will usually take a dairy products. Occasionally eats
mouth. dairy products) per day. Takes dairy products per day. Occasionally supplement when offered. OR between meals. Does not require
fluid poorly. Does not take a liquid will take a dietary supplement, OR supplementation.
IV: Intravenously. dietary supplement, OR Is on a feeding tube or TPN regimen,
Receives less than optimum amount of which probably meets most of nutritional
TPN: Total needs.
Is NPO¹ and/or maintained on clear liquid diet or tube feeding
parenteral nutrition. liquids or IV² for more than five
days.
FRICTION AND 1. PROBLEM 2. POTENTIAL PROBLEM 3. NO APPARENT PROBLEM

SHEAR
Requires moderate to maximum Moves freely or requires minimum Moves in bed and in chair independently
assistance in moving. Complete assistance. During a move, skin and has sufficient muscle strength to
lifting without sliding against probably slides to some extent against lift up completely during move.
sheet is impossible. Frequently sheets, chair, restraints, or other Maintains good position in bed or chair.
slides down in bed or chair, devices. Maintains relatively good
requiring frequent repositioning position in chair or bed most of the
with maximum assistance. time but occasionally slides down.
Spasticity, contractures, or
agitation leads to almost constant
friction.
RISK SCORES: AT RISK = 15 – 18 MODERATE RISK = 13 – 14 HIGH RISK = 10 – 12 VERY HIGH RISK = ≤ 9 TOTAL SCORE
British Columbia Provincial Nursing Skin and Wound Committee. (2014). Guideline: Braden scale for predicting pressure ulcer risk in adults and children.
Retrieved from https://www.clwk.ca/buddydrive/file/guideline-braden-risk-assessment/

WEEK NINE: MUSCULOSKELETAL ASSESSMENT WORKSHEETS
MUSCULOSKELETAL HEALTH HISTORY MARK OUT OF COMMENTS
O (Onset) 1
Q (Quality) 1
U (Understanding) 1
V (Values) 1
Joints—any problems with your joints? Yes/no 1

Do you have pain? Yes/no
Muscles - any problems in the muscles--any pain or 1

cramping?
Bones – Any bone pain? Yes/no 1
ADLs - Are you able to complete all your 1

activities of daily living? Yes/no
Mobility - are you able to walk, go up and down 1

stairs? Yes/no
Self-care - are there any occupational hazards at 1
your workplace that could affect your joints or
muscles?
Weight Changes Have you had any recent weight 2
changes? (gain or loss)
Medication Use: Aspirin, anti- 4
inflammatory, muscle relaxant, pain
reliever
TOTAL 24

TEMPOROMANDIBULAR JOINT MARK OUT OF COMMENTS
Temporomandibular Joint 2
▪ Inspection and palpation

▪ ROM (minimum of 1 test)
Demonstrates correct technique for palpation 1
Explains what is being examined for each area. 1
TOTAL 4
CERVICAL SPINE MARK OUT OF COMMENTS
Inspect alignment of head and neck 1
Palpate 3
▪ Spinous process
▪ Trapezius
▪ Paravertebral muscles
Perform ROM (minimum of 1 test) 1
Explains what is being examined for each area 1
TOTAL 7

UPPER EXTREMITY MARK OUT OF COMMENTS
Shoulders 2
▪ Inspect (posterior and anterior)

Elbow 3
▪ Inspect size and contour

▪ Palpate
Wrist and Hand 4
▪ Inspect hand and wrist on dorsal and palmar

sides
▪ Palpate wrist and hand joints
▪ Muscle Strength Testing (minimum of 1 test)
Demonstrates correct technique for each area 1
being examined
Explains what is being examined for each area of 1

the upper extremity
TOTAL 11

LOWER EXTREMITY MARK OUT OF COMMENTS
Hip 3
▪ Inspect hip joint

▪ Palpate hip joint
Knee 3
▪ Inspect knee shape and contour

▪ Palpate
Ankle and Foot 3
▪ Inspect ankle and foot while person is sitting

and standing
▪ Muscle strength testing (minimum of 1 test)
Explains what is being examined for each area of 1

the lower extremity
TOTAL 11

SPINE MARK OUT OF COMMENTS
Spine 3
▪ Inspect (posterior and side)

▪ Palpate
Explains what is being examined for each area 1
TOTAL 5

WEEK TEN: NEUROLOGICAL ASSESSMENT WORKSHEETS
NEUROLOGICAL HEALTH HISTORY MARK OUT OF COMMENTS
O (Onset) 1
Q (Quality) 1
U (Understanding) 1
V (Values) 1
Headaches (yes/no) if yes, complete OPQRSTUV 1
Head Injury – when did it happen, where was your
injury 1
Dizziness/ Vertigo – yes/no when did you last
experience this symptom 1
Seizures – yes/no can you describe what happens 1

Tremors – yes/no can you describe what happens 1
Weakness – yes/no where, can you describe what
happens, where do you feel the weakness 1
Numbness or Tingling – yes/no, can you describe

what happens, where do you feel the tingling 1
Difficulty Swallowing – yes/no 1

Difficulty Speaking – yes/no 1
Problems with Co-ordination and Balance – yes/no 1
Past History of Neurological Disorders – yes/no
1
Family History of Neurological Problems – yes/no 1
Exposure Environmental/Occupational Hazards –
yes/no 1
Medications (prescribed, OTC, herbal, recreational

drug use, supplements) 5
Allergies 1
TOTAL 31
MENTAL STATUS MARK OUT OF COMMENTS
Verbalize and demonstrates assessment of four (4)

components of mental status:
• Appearance, Behaviour, & Cognition:
Identify each assessment and
verbalize/demonstrate two (2) evaluation
strategies for each (6 marks)
• Thought Process/Thought
Content/Perception:
Identify two (2) assessments and
verbalize/demonstrate one (1) evaluation
strategy for each (2 marks)
ABCT
8
− Appearance - posture, body movements,
dress, grooming and hygiene
− Behaviour – LOC, facial expression, speech,
mood and affect
− Cognition – orientation, attention span,
immediate, recent and remote memory,
new learning
− Thought Processes (e.g. does the client
make sense); Thought Content (e.g.
what the patient says is logical and
consistent); Perceptions (e.g. client is
aware of reality)
Evaluates LOC – states level 1
TOTAL 9

CRANIAL NERVES MARK OUT OF COMMENTS
− Identifies the nerve number and name, and

completes appropriate bilateral testing for
cranial nerves
I – Olfactory 3
− Sniff and smell

II – Optic 3
− Visual acuity, confrontation
III, IV, and VI - Oculomotor, Trochlear,
Abducens
6
− Palpebral fissures are equal
− PERRLA, (Need to state- pupils equal,
round, reactive to light & accommodation)
− Extra Ocular Eye Movements (EOM)
V – Trigeminal
− Palpate temporal & masseter muscles 4
− Ask the person to clench their teeth
− Touch a cotton wisp to persons face,
forehead, cheeks and chin.
VII – Facial
− Assesses 6 facial expressions: smile, frown, 2
puff out cheeks, stick out tongue, lift
eyebrows, close eyes tightly against force
VIII – Acoustic 2
− Voice test (Whisper Test)

IX, X – Glossopharyngeal and Vagus 3
− Gag reflex and “Ah” voice sounds
XI – Spinal Accessory
− Movement of head & shoulders (move 2
head and shoulders against resistance)
XII – Hypoglossal 3
− Position of tongue
− Voice test (light, tight, dynamite)
TOTAL 28

MOTOR SYSTEM MARK OUT OF COMMENTS
INSPECTION AND PALPATION
MUSCLES
Inspects muscles of upper and lower 2
extremities bilaterally for size and tone
Tests strength of upper and lower extremities 2

bilaterally
CEREBELLAR FUNCTION
Test cerebellar function by assessing the following 3

balance tests:
− Gait
− Tandem walking
− Romberg test
Tests Coordination and skilled movement 1
− Rapid alternating movements
TOTAL 8
SENSORY SYSTEM MARK OUT OF COMMENTS
Identifies and tests for: 4

− Superficial pain (upper and lower extremities)
− Light touch (upper and lower extremities)
− Vibration (upper and lower extremities)
− Stereognosis
Verbalizes comparison of the right side with the left 1

side
TOTAL 5

REFLEXES MARK OUT OF COMMENTS
Identifies, tests and grades using correct technique 4

the deep tendon reflexes bilaterally. Verbalizes
testing results for:
− Biceps reflex
− Triceps reflex
− Patellar reflex
− Achilles reflex
(Scale on a 5-point scale: 2+ normal)
Verbalizes comparison of the right side with the 1

left side
TOTAL 5

GLASGOW COMA SCALE

MONTREAL COGNITIVE ASSESSMENT (MOCA)

MONTREAL COGNITIVE ASSESSMENT - BASIC (MOCA-B)
ADMINISTRATION AND SCORING INSTRUCTIONS
The Montreal Cognitive Assessment (MoCA) was designed as a rapid screening instrument for mild
cognitive impairment. The Montreal Cognitive Assessment – Basic (MoCA-B) was developed to
facilitate the detection of mild cognitive impairment in illiterate and lower educated subjects.
The MoCA-B assesses similar cognitive domains as the original MoCA: executive functions,
language, orientation, calculations, conceptual thinking, memory, visuoperception, attention,
and concentration. It takes approximately 15 minutes to administer the MoCA-B. It is scored on 30
points.
ALL INSTRUCTIONS MAY BE REPEATED ONCE EXCEPT IF OTHERWISE SPECIFIED.
START TIMING:
The examiner writes the time (hour-minutes-seconds) in the right-hand column of the test sheet
prior to administrating the first task (Executive Functions).
1. EXECUTIVE FUNCTION (ALTERNATING TRAIL MAKING)
The task is upside down to reduce manipulation of the test sheet; the examiner simply slides the
test sheet across the table to the subject (the numbers should be upright for the subject).
ADMINISTRATION:
The examiner gives the following instructions: “Please draw a line alternating between a square
with a number and a square with dots in increasing order. Begin here [point to the square with
the number 1] and draw a line from the square with the number 1 to the square with one dot
[point to the square with one dot]. Then draw a line to the square with the number
2 [point to the square with number 2] then to the square with two dots [point to the square with
two dots] and so on. End here [point to the square with six dots].”
SCORING:
The correct pattern is as follows:
1 1 point is allocated if the subject successfully draws the correct pattern on the first
attempt without any errors or self-corrections.
1 No points are allocated if the subject draws an incorrect pattern or makes an error, even if it is
immediately self- corrected.

2. IMMEDIATE RECALL
ADMINISTRATION:
The examiner gives the following instructions: “This is a memory test. I am going to read a list of
words that you will have to remember now and later on. Listen carefully. When I am through,
tell me as many words as you can remember. It doesn’t matter in what order you say them.”
The examiner reads the list of five words at a rate of one word per second. A checkmark is made
in the allocated space for each word the subject recalls on the first trial. When the subject
indicates that (s)he has finished (has recalled all words or can recall no more words), the examiner
gives the following instructions: “I am going to read the same list a second time. When I am
through, tell me as many words as you can remember, including words you said the first time.”
The examiner reads the list a second time and makes a checkmark in the allocated space for each
word the subject recalls on the second trial. At the end of the second trial, the examiner informs
the subject that (s)he will be asked to recall these words again by saying: “Try to remember these
words as I will ask you to recall these again at the end of the test.”
SCORING:
− No points are given for Trials One and Two.
1. FLUENCY
ADMINISTRATION:
The examiner gives the following instructions: “I want you to name as many FRUITS as you can think of.
I will tell you to stop after one minute. Go ahead. [Begin timing. After 60 seconds say:] Stop.” The
examiner records all the words to ensure that repeated words are not scored.
SCORING:
− 1 2 points are allocated if the subject generates 13 words or more.
− 1 1 point is allocated if the subject generates 8-12 words.
− 1 No points are allocated if the subject generates 7 words or less.
2. ORIENTATION
ADMINISTRATION:
The examiner gives the following instructions: “Without looking at your watch, tell me approximately
what time it is.” The examiner then says: “Now, tell me what day of the week it is and what month and
year it is.” “Tell me the name of this place and which city we are in.”
SCORING:
− 1 point is allocated for each correct answer.
o For the time, an answer within two hours of the actual time is accepted. The subject must
give the exact day of the week, month, year, place (name of hospital, clinic, office) and
city.

3. CALCULATION
ADMINISTRATION:
The examiner gives the following instructions: "Pretend you have several 1 dollar coins/bills and 5 and 10
dollar bills in your pocket. Please provide me with the maximum number of combinations to pay for an
item that costs 13 dollars. You cannot ask for change." If the subject provides a combination that requires
change, provide the following prompt once: “Are there any other combinations?” The examiner records the
subject’s answers in the space provided.
SCORING:
− 1 3 points are allocated if the subject provides 3 or 4 correct combinations.
− 1 2 points are allocated if the subject provides 2 correct combinations.
− 1 1 point is allocated if the subject provided 1 correct combination.
− 1 No points are allocated if the subject cannot provide any correct combination.
4. ABSTRACTION
ADMINISTRATION:
The subject is asked to provide the category to which a pair of words belongs to. The examiner gives the
following example: “To which category do an orange and a banana belong to?” If the subject answers in a
concrete manner, the examiner gives the following prompt once: “Can you tell me another category
these items belong to?” If the subject does not respond correctly [Fruits], the examiner says: “Yes, and
they both belong to the category Fruits”.
No additional instruction or clarification is given. After the practice trial, the first trial is administered:
“Now, tell me which category a train and a boat belong to?” If the first response given is concrete, the
examiner gives the following prompt once: “Can you tell me another category these items belong to?”
The second and third trials are administered using the same instructions as the first trial (with one
prompt permitted per item upon a concrete response).
SCORING:
The practice item is not scored (only the last three items are scored). 1 point is given for each category
correctly identified.
The following responses are acceptable:
− 1 train-boat: means of transportation, travelling, vehicles.

− 1 north-south: cardinal directions, cardinal points, directions, hemispheres, regions.
− 1 drum-flute: musical instruments.
The following responses are not acceptable:
− 1 train-boat: made of iron, have engines, consume oil, petrol or gasoline.

− 1 drum-flute: made from wood or any other material, produce sound.

5. DELAYED RECALL
ADMINISTRATION:
The examiner gives the following instruction: “I read some words to you earlier, which I asked you to
remember. Tell me as many of those words as you can remember.” The examiner identifies each word
correctly recalled without any cues by making a checkmark (√ ) in the allocated space.
SCORING:
− 1 point is allocated for each word recalled without any cues.
CUEING:
Following the delayed free recall trial, the examiner provides a category (semantic) cue for each word the
subject was unable to recall. Example: ‘‘I will give you some hints to see if it helps you remember the words,
the first word was a type of flower.’’ If the subject is unable to recall the word with the category cue, the
examiner provides him/her with a multiple choice cue. Example: “Which of the following words do you think
it was ROSE, DAISY or TULIP?” All non-recalled words are prompted in this manner. The examiner identifies
the words the subject was able to recall with the help of a cue (category or multiple-choice) by placing a
checkmark (√) in the appropriate space. The cues for each word are presented below:
− ROSE: category cue: type of flower multiple choice: rose, daisy, tulip
− CHAIR: category cue: type of furniture multiple choice: table, chair, bed
− HAND: category cue: body part multiple choice: foot, hand, knee
− BLUE: category cue: colour multiple choice: blue, brown, red
− SPOON: ategory cue: kitchen instrument multiple choice: fork, spoon, knife
SCORING:
No points are allocated for words recalled with a cue.
− The use of cues provides clinical information on the nature of the memory deficits. For memory deficit
due to retrieval failures, performance can be improved with a cue. For memory deficits due to encoding
failures, performance does not improve with a cue.
6. VISUOPERCEPTION
ADMINISTRATION:
Pointing to the drawing of the superimposed objects on the complementary work sheet, the examiner says:
‘‘I would like you to look at this drawing and identify as many objects as you can. If you cannot name some
of the objects, outline them with your finger or tell me about their function. You may not rotate the picture.
You have 1 minute to identify as many objects as you can. Are you ready? Begin." [Start timing]. The subject
is stopped after 60 seconds. The examiner circles each object correctly identified on the scoring sheet.
SCORING:
The drawing is composed of 10 objects: scissors, cup, T-shirt, watch, banana, leaf, lamp, key, candle and
spoon.
− 3 points are allocated if the subject can identify 9-10 objects.
− 1 2 points are allocated if the subject can identify 6-8 objects.
− 1 point is allocated if the subject can identify 4-5 objects.
− 1 No point is allocated if the subject can identify 3 objects or less.
7. NAMING
ADMINISTRATION:
Pointing to each animal on the complementary worksheet, the examiner says:
“Tell me the name of this animal.”
SCORING:
1 point is awarded for each correct answer:
− 1 ZEBRA (Horse and donkey are not accepted)

− 1 PEACOCK (Bird, chicken or other kind of birds are not accepted)
− 1 TIGER (Cheetah, leopard and black tiger are not accepted)
− 1 BUTTERFLY (Insect or other kind of insects are not accepted)
8. ATTENTION - NUMBERS WITH WHITE BACKGROUND
ADMINISTRATION:
Pointing to the row of numbers with a white background on the complementary worksheet, the examiner
says: "Looking at the row of numbers with a white background, please read out loud the numbers in the
CIRCLES only. Do not read the numbers in the squares or triangles. Start here [point to the beginning of the
row ( )] and end here [point to the end of the row ( )].”
SCORING:
− 1 1 point is allocated if the subject completes the task with 1 error or less.
− 1 No point is allocated if the subject completes the task with 2 errors or more.
An error is defined as follows: Reading a number which is not in a circle, omitting to read a number in a
circle or reading numbers in the incorrect order (example: returning to a previous number). The number
of errors is recorded in the space provided on the scoring sheet.
9. NUMBERS WITH BLACK BACKGROUND
ADMINISTRATION:
Pointing to the row of numbers with a white background on the complementary worksheet, the examiner
says: "Looking at the row of numbers with a dark background, please read out loud the numbers in the
CIRCLES and SQUARES. Do not read the numbers in the triangles. Start here [point to the beginning of the
first row ( )], go through both rows [run your finger across the top then bottom row from left to right]
and stop here [point to the end of the second row ( )].”
SCORING:
− 1 2 points are allocated if the subject completes the task with 2 errors or less.
− 1 1 point is allocated if the subject completes the task with 3 errors.
− 1 No point is allocated if the subject completes the task with 4 errors or more.

An error is defined as follows: Reading a number which is not in a circle or a square, omitting to read a
number in a circle or a square or reading numbers in the incorrect order (example: returning to a previous
number). The number of errors is recorded in the space provided on the scoring sheet.
TOTAL SCORE:
SUM ALL SUB-ITEM SCORES LISTED IN THE RIGHT-HAND COLUMN OF THE SCORING SHEET. THE MAXIMUM SCORE
IS 30 POINTS.
− 1 To correct for any residual education bias, 1 point is added to the total
score of subjects with less than 4 years of education (if score is <30).
− 1 To correct for literacy, 1 point is added to the score of subjects considered illiterate, regardless of
the
PARTICIPANT’S EDUCATION LEVEL (IF SCORE IS <30). ILLITERACY IS DEFINED AS THE INABILITY TO READ OR
WRITE FLUENTLY IN DAILY LIVING.
NASREDDINE, Z. (ND). MONTREAL COGNITIVE ASSESSMENT (MOCA). RETRIEVED FROM

HTTP://WWW.MOCATEST.ORG/

WEEK ELEVEN: ABDOMINAL ASSESSMENT WORKSHEETS:
ABDOMINAL HEALTH HISTORY MARK OUT OF COMMENTS
O (Onset) 1
Q (Quality) 1
U (Understanding) 1
V (Values) 1
Any changes in appetite, weight gain 3

and weight loss?
Dysphagia? 1
Food Intolerance? 1
Abdominal Pain? 1
Nausea/ Vomiting? 1
Bowel Habits 1
Past History of Abdominal Disorders? 1
Nutritional Assessment: 24 – hour recall 1
Family history of Abdominal Disorders? 1
Medication Use (prescribed, OTC, herbal, 5

Allergies 1
TOTAL 29

PHYSICAL EXAMINATION OF MARK OUT COMMENTS
ABDOMINAL SYSTEM - INSPECTION OF
Contour (flat, rounded) 1
Symmetry (symmetric bilaterally) 1
Umbilicus (midline, inverted) 1
Skin (smooth, even, homogenous colour, 1

striae, lesions, or moles)
Pulsation or movement (pulsation from aorta) 1
Demeanor of client (relaxed facial 1

expression, slow even respirations)
TOTAL 6
PHYSICAL EXAMINATION OF MARK OUT COMMENTS

ABDOMINAL SYSTEM - AUSCULTATION OF
Auscultates all four (4) quadrants before 1
palpation or percussion;
Describes rationale for this order
Auscultates all four (4) quadrants for 1

bowel sounds using the diaphragm of the
stethoscope
Listens first in right lower quadrant (R.L.Q.) 1
and progresses in a clockwise fashion (unless
it is the painful quadrant; needs to ask /
determine abdominal pain)
Determines the character and frequency of 1
bowel sounds (High Pitched 5 – 30)
Identifies, landmarks and auscultates for 1
vascular sounds for: Aorta, Renal, Iliac &
Femoral
Auscultates vascular sounds using the bell 1
of the stethoscope
Describes bruit and explains it as a finding 1
TOTAL 7

PHYSICAL EXAMINATION OF ABDOMINAL MARK OUT COMMENTS
SYSTEM - PERCUSSION OF
Percusses all four (4) quadrants with 1

correct technique
Determines and describes predominate 1

note (Tympany)
TOTAL 2
PHYSICAL EXAMINATION OF ABDOMINAL MARK OUT COMMENTS

SYSTEM - PALPATION
OF
Asks / determines if there is abdominal 1

pain; palpates tender areas last
Lightly palpates all four (4) quadrants of 2

abdomen for:
− masses
− tenderness
Describes the assessment for and explains 2

findings:
− voluntary guarding
− involuntary rigidity
− Demonstrates correct technique for light 1

palpation
TOTAL 6

NUTRITION ASSESSMENT WORKSHEETS
WITH YOUR LAB PARTNER:
1. Complete a Nutritional Health History. Nutritional assessment and nursing practice.
2. Complete the 24 – Hour Record of Food Intake Form
3. Compare your partner’s intake with Eating Well with Canada’s Food Guide, 2017—
accessed at the following web link:
http://www.eatrightontario.ca/en/Articles/Canada-s-Food-Guide/Eating-well-with-Canada-s-
Food- Guide.aspx
4. Complete the following anthropometric measurements:

a. Height
b. Weight
c. Waist to Hip Ratio
5. Interpret the anthropometric findings

NUTRITION SCREENING FORMS — (24 HOUR RECORD OF FOOD INTAKE)
BREAKFAST
AMOUNT &
FOOD/BEVERAGE TYPE AND/OR METHOD OF PREPARATION
TIME EATEN
MILK
FRUIT
− Fresh
− Canned
− Sweetened
− Other
CEREAL − Brand
− with milk with sugar
− other
BREAD − White
− margarine/butter − Whole wheat
− mayonnaise
EGGS, MEAT OR
OTHER PROTEIN
BEVERAGE
− with milk
− with sugar
− other
OTHER FOODS
− Did you eat a mid-morning snack? Yes/No

− If yes, then list time and type of food(s)/beverage(s) consumed:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________

NOON MEAL
FOOD/BEVERAGE TYPE AND/OR METHOD OF PREPARATION AMOUNT & TIME
EATEN
SOUP
BREAD White Whole wheat
− margarine/butter
mayonnaise
− other
EGGS, MEAT OR OTHER
PROTEIN
VEGETABLES
− cooked raw
− topping/seasoning
− (butter, white sauce,
− cheese sauce, etc.)
SALAD
− dressing (brand, etc.)
FRUIT
− Fresh
− Canned
− Sweetened
MILK
BEVERAGE
− with milk
− with sugar
− other
DESSERT
OTHER FOODS
Did you eat a mid-morning snack? Yes/No
−
If yes, then list time and type of food(s)/beverage(s) consumed:
−
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
VENING MEAL
FOOD/BEVERAGE TYPE AND/OR METHOD OF AMOUNT &
PREPARATION TIME EATEN
MAIN DISH
− meat
− cheese poultry other
− protein pasta
− rice
VEGETABLES
− cooked raw
− topping/seasoning
− (butter, white sauce,
− cheese sauce, etc.)
SALAD - type
− dressing (brand, etc.)

BREAD White Whole wheat
− margarine/butter
mayonnaise
− other
FRUIT
− Fresh
− Canned
− Sweetened
MILK
BEVERAGE
− with milk
− with sugar
− other
DESSERT
OTHER FOODS
Did you eat a mid-morning snack? Yes/No

−
If yes, then list time and type of food(s)/beverage(s) consumed:
−
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________

BSCN 2020 Lab Manual W2024

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BSCN 2020

BScN 2020 Health Assessment_W2024 Page 1 of 73

− Student independent preparation

DRESS CODE, CODE OF CONDUCT, ATTENDANCE AND PARTICIPATION

Elsevier (2023) Canadian Clinical Skills: Essentials Collection - eCommerce Version.

− Communication and − General Survey

BScN 2020 Health Assessment_W2024 Page 3 of 73

BScN 2020 Health Assessment_W2024 Page 4 of 73

− All Professional and Essential Behaviours (infection control, professionalism, interview)

PHYSICAL EXAM AND HEALTH ASSESSMENT:

PROFESSIONAL AND ESSENTIAL BEHAVIOURS

Infection Control Yes No Comments

Use of personal protective equipment as needed

Patient identifiers (two)

Explains health history and physical exam procedure

Conducts a focused, systematic, accurate and

Dressed according to Humber College uniform policy

BScN 2020 Health Assessment_W2024 Page 5 of 73

Greet client by proper name

Wear appropriate attire

Provide a clear introduction to the interview

State the time available for the interview

State the purpose of the interview

Indicate the role of each participant

If an adolescent or adult, ask permission from

Indicate confidentiality of the interview and

Use verbal responses appropriately (see nine

Use appropriate non-verbal behaviour

Respond appropriately to client’s non-

Use appropriate terminology/language

Close the interview with a summary of the

Uses polite signal that the interview is complete

Consider special needs of the client

BScN 2020 Health Assessment_W2024 Page 6 of 73

BIOGRAPHICAL DATA (SOURCE OF HISTORY)

REASON FOR SEEKING CARE

CURRENT HEALTH OR HISTORY OF CURRENT ILLNESS (SYMPTOM ANALYSIS)

BScN 2020 Health Assessment_W2024 Page 7 of 73

Most Recent Examination

BScN 2020 Health Assessment_W2024 Page 8 of 73

General Overall Health State

Head, Eyes, Ears,

BScN 2020 Health Assessment_W2024 Page 9 of 73

Sleep and Rest

Coping and Stress

BScN 2020 Health Assessment_W2024 Page 10 of 73

BScN 2020 Health Assessment_W2024 Page 11 of 73

Sex (sexual development consistent with gender & age)

Level of Consciousness (state the correct LOC based on assessment)

Skin Colour (consistent with ethnic background, skin intact no lesions)

Facial Features (symmetrical)

Position (sitting, standing, laying, examination table-comfortable)

BScN 2020 Health Assessment_W2024 Page 12 of 73

Range of Motion (full mobility, smooth movement)

Mood & Affect (comfortable, cooperative)

Speech (clear articulation, clear, fluent)

Dress (appropriate to climate, clean)

Personal Hygiene (clean, groomed)

BScN 2020 Health Assessment_W2024 Page 13 of 73