OUR LADY OF FATIMA UNIVERSITY

COLLEGE OF NURSING - PAMPANGA

PROGRAM Bachelor of Science in Nursing Student Name

Year and Section
COURSE HEALTH ASSESSMENT Instructor
Date

PROCEDURE : Taking Body Temperature, Pulse Rate, and Respiration

EXPECTED OUTCOME : The student should be able to perform taking body temperature, pulse rate
and respiratory rate
ASESSMENT TASK : Return demonstration

Exceptional Good Average Poor

Assessment Dimension SCORE
(3) (2) (1) (0)
1. Prepare Gathered materials Gathered materials Gathered Failed to gather
equipment such needed with little time materials with all the materials
as oral glass, preparation more time needed
preparation
thermometer,
cotton balls
(with and
without alcohol)
and wrist hand
with second
hand

2. Wash hands Observed principles Hand washing was Hand washing was Hand washing
before starting of medical hand done with minimal done with maximal was not done
the procedure washing error error

3. Identify the Greeted and Performed the two Performed the one Failed to identify
patient and identified client by (2) ways of (1) ways of the client
explain the asking his/her name identifying the the identifying the the
and checking his or client client
procedure
her ID band politely
4. Provide privacy Provided privacy Provided privacy Provided privacy
Failed to provide
during the entire but not in the entire but was observed
privacy
procedure procedure only at times
5. Place the client Properly and skillfully Placed the client Placed client Failed to
in an positioned the client comfortably and in comfortably and in positioned client
appropriate comfortably any preferable any preferable properly and
position position with less position with comfortably
supervision maximum
supervision
6. Obtain the Performed the Performed the Performed the Failed to perform
thermometer procedures with ease procedures with procedures with the procedure
from the minimal supervision maximum
container supervision
7. Wipe Performed the Performed the Performed the Failed to perform
thermometer procedures with ease procedures with procedures with the procedure
with cotton ball minimal supervision maximum
with alcohol supervision
from the bulb to
the stem. Dry it
using cotton
balls in the same
manner.
8. Check the Performed the Performed the Performed the Failed to perform
battery and or procedures with ease procedures with procedures with the procedure
the minimal supervision maximum
thermometer if supervision
functioning
9. Using snapping Performed the Performed the Performed the Failed to perform
wrist action, procedures with ease procedures with procedures with the procedure
instruct patient minimal supervision maximum
 to open his supervision
mouth and raise
the tongue
Performed the Performed the Performed the Failed to perform
10. Place the
procedures with ease procedures with procedures with the procedure
thermometer in
minimal supervision maximum
client’s axilla
supervision
11. Leave the Performed the Performed the Performed the Failed to perform
thermometer procedures with ease procedures with procedures with the procedure
(while waiting minimal supervision maximum
the nurse may supervision
count the client’s
radial pulse and
respiration)
ASSESSING THE
RADIAL PULSE
12. While taking the Performed the Performed the Performed the Failed to perform
client’s body procedures with ease procedures with procedures with the procedure
temperature, minimal supervision maximum
begin to assess supervision
his radial pulse
rate
13. Position client’s Performed the Performed the Performed the Failed to perform
body procedures with ease procedures with procedures with the procedure
temperature, minimal supervision maximum
begin to assess supervision
the radial pulse
rate
14. Support client’s Performed the Performed the Performed the Failed to perform
wrist by grasping procedures with ease procedures with procedures with the procedure
outer aspect of minimal supervision maximum
the thumb. Place supervision
index and
middle finger
over the client’s
artery and
palpate pulse
15. Count pulse to Performed the Performed the Performed the Failed to perform
one full minute procedures with ease procedures with procedures with the procedure
using wrist minimal supervision maximum
watch with supervision
second hand.
Performed the Performed the Performed the Failed to perform
16. Assess rhythm, procedures with ease procedures with procedures with the procedure
volume of pulse minimal supervision maximum
supervision
ASSESSING
RESPIRATION
17. After taking the Performed the Performed the Performed the Failed to perform
pulse rate, do procedures with ease procedures with procedures with the procedure
not remove minimal supervision maximum
fingers from the supervision
wrist. Observe
the chest
movement while
supposedly
taking the radial
pulse
18. Count the Performed the Performed the Performed the Failed to perform
respiratory rate procedures with ease procedures with procedures with the procedure
for one full minimal supervision maximum
minute. An supervision
inhalation and
exhalation is
counted as one
respiration. This
 is observed with
the rise and fall
of the chest wall.
19. Observe the Performed the Performed the Performed the Failed to perform
depth, rhythm, procedures with ease procedures with procedures with the procedure
and character of minimal supervision maximum
respiration. supervision
20. Remove the Performed the Performed the Performed the Failed to perform
thermometer procedures with ease procedures with procedures with the procedure
from the client’s minimal supervision maximum
axilla. Read at supervision
eye level.
21. Wipe it with Performed the Performed the Performed the Failed to perform
cotton balls with procedures with ease procedures with procedures with the procedure
alcohol from minimal supervision maximum
stem to bulb supervision
Performed the Performed the Performed the Failed to perform
22. Return the
procedures with ease procedures with procedures with the procedure
thermometer to
minimal supervision maximum
proper container
supervision
23. Wash hands and Washed hands and Washed hands and Washed hands but Washed hands
document documented the some of the details most of the details but
reading of body information about of procedure were of the procedure documentation
the procedure and not documented were not was not done
temperature,
properly and documented
pulse and
completely
respiration.

OVERALL SCORE: ________________

Target raw score is 52 out of 69. If raw score is less than 52, repeat the return demonstration.

___________________________________

FACULTY SIGNATURE OVER PRINTED NAME

 OUR LADY OF FATIMA UNIVERSITY
COLLEGE OF NURSING - PAMPANGA

PROGRAM Bachelor of Science in Nursing Student Name

Year and Section
COURSE HEALTH ASSESSMENT Instructor
Date

PROCEDURE : Assessing the Abdomen

EXPECTED OUTCOME : The student should be able to perform assessing the abdomen
ASESSMENT TASK : Return demonstration

Exceptional Good Average Poor

Assessment Dimension SCORE
(3) (2) (1) (0)
1. Prepare Gathered materials Gathered materials Gathered Failed to gather
equipment: examining needed with little time materials with all the materials
light tape measure, preparation more time needed
preparation
water-soluble
skin-marking pencil and
stethoscope

Observed principles Hand washing was Hand washing was

Hand washing
2. Wash hands of medical hand done with minimal done with maximal
was not done
washing error error
Greeted and Performed the two Performed the one Failed to identify
3. Greet and identify identified client by (2) ways of (1) ways of the client
asking his/her name identifying the the identifying the the
client. .
and checking his or client client
her ID band politely
Explained procedure Explained the Explained the Failed to explain
and its purpose to procedure but lack procedure but in procedure and its
4. Explain the procedure the client clearly and some details. an unclear purpose.
completely with manner.
client’s consent
Provided privacy Provided privacy Provided privacy
Failed to provide
5. Provide client’s privacy during the entire but not in the entire but was observed
privacy
procedure procedure only at times
6. Inquire client’s Performed the Performed the Performed the Failed to perform
history of bowel habits, procedures with ease procedures with procedures with the procedure
change in appetite, minimal supervision maximum
specific abdominal signs supervision
and symptoms,
hematemesis, previous
and current problems and
treatment

7. Position client in Performed the Performed the Performed the Failed to perform
a supine position with the procedures with ease procedures with procedures with the procedure
arms placed comfortably minimal supervision maximum
at the sides. Place small supervision
pillows beneath the
knees and the head to
reduce tension in the
abdominal muscle.
Expose only the client’s
abdomen from chest line
to the pubic area

8. Observe for contour Performed the Performed the Performed the Failed to perform
and symmetry. If procedures with ease procedures with procedures with the procedure
distention is present, minimal supervision maximum
measure the abdominal supervision
girth with a tape measure
9. Observe abdominal Performed the Performed the Performed the Failed to perform
movements associated procedures with ease procedures with procedures with the procedure
with respiration, minimal supervision maximum
peristalsis or aortic supervision
pulsation
Performed the Performed the Performed the Failed to perform
10. Observe for scars, procedures with ease procedures with procedures with the procedure
striae, rashes, and lesions minimal supervision maximum
supervision
11. Auscultate the Performed the Performed the Performed the Failed to perform
abdomen before procedures with ease procedures with procedures with the procedure
percussing and palpating minimal supervision maximum
to avoid stimulating supervision
intestinal activity and
altering bowel sounds
12. In all quadrants, listen Performed the Performed the Performed the Failed to perform
for active bowel-sounds - procedures with ease procedures with procedures with the procedure
irregular gurgling noises minimal supervision maximum
occurring about every supervision
5-10 seconds. Note:
frequency, pitch and
duration of sounds
13. Auscultate for bruits Performed the Performed the Performed the Failed to perform
over the abdominal aorta procedures with ease procedures with procedures with the procedure
and the renal, iliac, and minimal supervision maximum
femoral arteries. supervision
14. Percuss all quadrants. Performed the Performed the Performed the Failed to perform
Note areas of tympany or procedures with ease procedures with procedures with the procedure
dullness. Use a systematic minimal supervision maximum
pattern. Begin in the supervision
lower left quadrant,
proceed to the lower
right quadrant, the upper
right quadrant and the
upper left quadrant
15. Percuss liver size Performed the Performed the Performed the Failed to perform
starting in the right procedures with ease procedures with procedures with the procedure
midclavicular line below minimal supervision maximum
the level of the umbilicus supervision
and moving upward and
downward to locate the
liver border
Performed the Performed the Performed the Failed to perform
16. Strike at the
procedures with ease procedures with procedures with the procedure
costovertebral angles,
minimal supervision maximum
noting tenderness or pain
supervision
17. Palpate the Performed the Performed the Performed the Failed to perform
abdomen lightly in all procedures with ease procedures with procedures with the procedure
quadrant and follow with minimal supervision maximum
deep palpation. Assess supervision
organ location and
abdominal muscle tone.
Note unusual masses,
pulsations, tenderness or
pain

18. Palpate kidneys Performed the Performed the Performed the Failed to perform
bimanually slightly below procedures with ease procedures with procedures with the procedure
the umbilicus. Note size, minimal supervision maximum
shape and tenderness. supervision

Performed the Performed the Performed the Failed to perform

19. Palpate abdominal
procedures with ease procedures with procedures with the procedure
aorta for contour and
minimal supervision maximum
pulsations
supervision
20. Palpate for Performed the Performed the Performed the Failed to perform
inguinal and femoral procedures with ease procedures with procedures with the procedure
lymph nodes bilaterally. minimal supervision maximum
Note for enlargement supervision

Performed the Performed the Performed the Failed to perform

21. Position client
procedures with ease procedures with procedures with the procedure
comfortably in bed after
minimal supervision maximum
assessment
supervision
Performed the Performed the Performed the Failed to perform
22. Inform client findings procedures with ease procedures with procedures with the procedure
as necessary minimal supervision maximum
supervision
Washed hands and Washed hands and Washed hands but Washed hands
documented the some of the details most of the details but
23. Wash hands and information about of procedure were of the procedure documentation
document the procedure. the procedure and not documented were not was not done
properly and documented
completely

OVERALL SCORE: ________________

Target raw score is 52 out of 69. If raw score is less than 52, repeat the return demonstration.

___________________________________
FACULTY SIGNATURE OVER PRINTED NAME
 OUR LADY OF FATIMA UNIVERSITY
COLLEGE OF NURSING - PAMPANGA

PROGRAM Bachelor of Science in Nursing Student Name

Year and Section
COURSE HEALTH ASSESSMENT Instructor
Date

PROCEDURE : Assessing the Neurological System

EXPECTED OUTCOME : The student should be able to perform assessing the Neurological System
ASESSMENT TASK : Return demonstration

Exceptional Good Average Poor

Assessment Dimension SCORE
(3) (2) (1) (0)
1. Prepare equipment: Gathered materials Gathered materials Gathered Failed to gather
percussion hammer, needed with little time materials with all the materials
tongue depressor, wisps preparation more time needed
of cotton, test tubes of preparation
hot and cold water.
Observed principles Hand washing was Hand washing was
Hand washing
2. Wash hands. of medical hand done with minimal done with maximal
was not done
washing error error
Greeted and Performed the two Performed the one Failed to identify
identified client by (2) ways of (1) ways of the client
3. Greet and identify
asking his/her name identifying the the identifying the the
client.
and checking his or client client
her ID band politely
Explained procedure Explained the Explained the Failed to explain
and its purpose to procedure but lack procedure but in procedure and its
4. Explain the procedures the client clearly and some details. an unclear purpose.
completely with manner.
client’s consent
Provided privacy Provided privacy Provided privacy
5. Provide for client Failed to provide
during the entire but not in the entire but was observed
privacy privacy
procedure procedure only at times
Placed client
Placed the client
comfortably and in Failed to
Properly and skillfully comfortably and in
6. Position client any preferable positioned client
positioned the client any preferable
appropriately position with properly and
comfortably position with less
maximum comfortably
supervision
supervision
7. Note the components Performed the Performed the Performed the Failed to perform
of the neurological procedures with ease procedures with procedures with the procedure
examination. minimal supervision maximum
a. Mental status.
supervision
b. Cranial nerve
function.
c. Cerebellar function.
d. Motor function.
e. Sensory function
f. Reflexes.

8. Assess mental status: Performed the Performed the Performed the Failed to perform
during history taking, procedures with ease procedures with procedures with the procedure
determine the state of minimal supervision maximum
consciousness. Note supervision
whether the client is
alert, somnolent,
stuporous or comatose

9. Assess for orientation Performed the Performed the Performed the Failed to perform
to person, place and procedures with ease procedures with procedures with the procedure
time. minimal supervision maximum
supervision
10. Assess for memory, Performed the Performed the Performed the Failed to perform
including immediate, procedures with ease procedures with procedures with the procedure
recent and remote minimal supervision maximum
supervision
11. Assess for cognition, Performed the Performed the Performed the Failed to perform
including calculations, procedures with ease procedures with procedures with the procedure
current events and minimal supervision maximum
response to proverbs supervision

12. Assess for judgment Performed the Performed the Performed the Failed to perform
and problem solving procedures with ease procedures with procedures with the procedure
ability minimal supervision maximum
supervision
13. Assess for emotion, Performed the Performed the Performed the Failed to perform
including mood, affect procedures with ease procedures with procedures with the procedure
and congruence of minimal supervision maximum
response supervision

14. Assess cranial nerve Performed the Performed the Performed the Failed to perform
(CN) functions. Olfactory procedures with ease procedures with procedures with the procedure
nerve (CNI). With the minimal supervision maximum
client’s eyes close, supervision
present various odors,
occluding one nostril at a
time. Note the client’s
ability to identify the
odor.

15. Optic nerve (CNII). Performed the Performed the Performed the Failed to perform
Test visual acuity and procedures with ease procedures with procedures with the procedure
visual fields. Examine the minimal supervision maximum
optic disc with an
supervision
ophthalmoscope
16. Oculomotors (CNIII). Performed the Performed the Performed the Failed to perform
Trochlear (CNIV) and procedures with ease procedures with procedures with the procedure
abducens (CNVI) nerves. minimal supervision maximum
Assess
supervision
extraoculomotor motion.
- Evaluate the six
cardinal positions of gaze.
Look for parallelism, and
note nystagmus
(involuntary movement).
- Perform the
cover/uncover test. Note
movement of the eye
when uncovered or
opposite eye when
contralateral eye covered.
Assess corneal light
reflex. Note symmetry of
reflection to light of the
pupils and pupillary
reaction to light and
accomodations.
17. Facial nerve Performed the Performed the Performed the Failed to perform
(CNVII). procedures with ease procedures with procedures with the procedure
Motor. Assess symmetry minimal supervision maximum
of facial movements as
supervision
the client smiles, frowns,
grimaces, clenches his
teeth and so forth.
Sensory. Ask the client to
identify various distinct
flavors placed on the
anterior two thirds of the
tongue

18. Acoustic nerve Performed the Performed the Performed the Failed to perform
(CNVIII). procedures with ease procedures with procedures with the procedure
- Vestibular branch. minimal supervision maximum
Perform the
supervision
Romberg test to
evaluate equilibrium.
Have the client stand
with feet together
and eyes closed for
 20-30 seconds
without support.
Note excessive
swaying.
- Cochlear branch.
Assess client’s ability
to hear spoken words
and vibration of
tuning fork.
19. Glossopharynge Performed the Performed the Performed the Failed to perform
al nerve (CNIX). procedures with ease procedures with procedures with the procedure
Motor. Ask client to move minimal supervision maximum
tongue from side to side
supervision
and up and down. Test for
the gag reflex by gently
touching the posterior
pharyngeal wall with a
tongue blade. Sensory.
Apply tastes on posterior
tongue for identification
20. Vagus Nerve (CNX). Performed the Performed the Performed the Failed to perform
Ask client to swallow and procedures with ease procedures with procedures with the procedure
note swallowing and minimal supervision maximum
vocal cord movement.
supervision
Assess client’s speech for
hoarseness
21. Accessory nerve Performed the Performed the Performed the Failed to perform
(CNXI). Assess strength of procedures with ease procedures with procedures with the procedure
the sternocleidomastoid minimal supervision maximum
and upper trapezius
supervision
muscles by asking the
client to move the head
against resistance of
your hand. Observe and
palpate the contraction of
the sternocleidomastoid
muscle on the opposite
resistance of your hands.

22. Hypoglossal nerve Performed the Performed the Performed the Failed to perform
(CNXII). Test strength and procedures with ease procedures with procedures with the procedure
articulation of the tongue minimal supervision maximum
by having the client push
supervision
the tongue to the side of
the mouth against
resistance applied to the
cheek. Ask the client to
stick out of the tongue
and then returns it
to the mouth while you
observe for deviation,
asymmetry, tremors and
fasciculations

23. Cerebellar function. Performed the Performed the Performed the Failed to perform
Assess posture, gait and procedures with ease procedures with procedures with the procedure
balance. Have the client minimal supervision maximum
walk forward and supervision
backward in a straight
line.

24. Assess coordination in Performed the Performed the Performed the Failed to perform
the upper extremities by procedures with ease procedures with procedures with the procedure
having the client perform minimal supervision maximum
the finger to nose test. supervision
25. Assess coordination in Performed the Performed the Performed the Failed to perform
the lower extremities by procedures with ease procedures with procedures with the procedure
having the client tap the minimal supervision maximum
toes and slide the heel
supervision
down the contralateral
skin
26. Motor function. Performed the Performed the Performed the Failed to perform
Muscle mass. Assess procedures with ease procedures with procedures with the procedure
symmetry and minimal supervision maximum
distribution distally and supervision
proximally, and
circumference of
extremities
27. Tone. Evaluate Performed the Performed the Performed the Failed to perform
resistance of muscles in procedures with ease procedures with procedures with the procedure
response to passive minimal supervision maximum
motion during flexion and
supervision
extension of extremities
28. Strength. Assess Performed the Performed the Performed the Failed to perform
hands and squeeze procedures with ease procedures with procedures with the procedure
muscle strength in each minimal supervision maximum
extremity against
supervision
resistance during flexion
and extension (abduction
and adduction)
comparing bilaterally.
Rate on a 5-point scale.
(0-absence, 1-trace,
2-poor, 3-fair/good,
5-normal).
29. Observe for Performed the Performed the Performed the Failed to perform
involuntary movements procedures with ease procedures with procedures with the procedure
(tremors, tics, twitching, minimal supervision maximum
fasciculation), and
supervision
abnormal postures (fetal,
decorticate or
decerebrate).
30. Sensory function. Performed the Performed the Performed the Failed to perform
Light touch. With procedures with ease procedures with procedures with the procedure
client’s eyes closed, have minimal supervision maximum
the client indicate
supervision
response to cotton wisp
lightly stroked on the
skin. (Back of hands,
forearms and upperarms,
torso, thigh, tibia and
dorsal portion of foot).
Compare bilaterally and
distal proximal.
31. Pain. Repeat the Performed the Performed the Performed the Failed to perform
pattern of light touch procedures with ease procedures with procedures with the procedure
assessment, using a minimal supervision maximum
sterile safety pin to elicit
supervision
sharp sensation.
Alternate with pin’s
rounded end for contrast.
32. Stereognosis. Performed the Performed the Performed the Failed to perform
Ask the client to identify procedures with ease procedures with procedures with the procedure
small objects placed in his minimal supervision maximum
hands, one at a time.
supervision

33. Graphesthesia. Performed the Performed the Performed the Failed to perform
Ask the client to identify a procedures with ease procedures with procedures with the procedure
number that is trace in minimal supervision maximum
his palm with your finger
supervision
tip.

34. Deep Tendon Performed the Performed the Performed the Failed to perform
Reflexes. Striking with a procedures with ease procedures with procedures with the procedure
reflex hammer, compare minimal supervision maximum
reflex amplitude
supervision
bilaterally, grading on a
4-point (4+ - hyperactive,
2+ or 3+ - average; 1+ -
diminished, 0 – no
response).
35. Brachioradials (C5, Performed the Performed the Performed the Failed to perform
C6). Strike the radius procedures with ease procedures with procedures with the procedure
tendon about 1 – 2 inches minimal supervision maximum
above the wrist. Observe
supervision
the flexion and
supination of the
forearm.
36. Biceps (C5, C6). Place Performed the Performed the Performed the Failed to perform
your thumb or forefinger procedures with ease procedures with procedures with the procedure
at the base of the biceps minimal supervision maximum
tendon and strike it.
supervision
Observe for flexion of the
arm at the elbow.

37. Triceps (C7, C8). Strike Performed the Performed the Performed the Failed to perform
the triceps tendon just procedures with ease procedures with procedures with the procedure
above the elbow. Observe minimal supervision maximum
for slight elbow extension supervision
38. Patellar quadriceps Performed the Performed the Performed the Failed to perform
(L2, L3, L4). Sharply strike procedures with ease procedures with procedures with the procedure
the patellar tendon. minimal supervision maximum
Observe the extension of
supervision
the knee.
39. Achilles Ankle Jerk Performed the Performed the Performed the Failed to perform
(S1, S2). Support the procedures with ease procedures with procedures with the procedure
client’s foot in the minimal supervision maximum
dorsiflexed position; tap
supervision
the Achilles tendon and
observe for plantar
flexion.
40. Superficial Cutaneous Performed the Performed the Performed the Failed to perform
Reflexes. procedures with ease procedures with procedures with the procedure
a. Abdominal. Stroke minimal supervision maximum
the abdomen above (T8,
supervision
T9, T10) and below (T10,
T11, T12) the umbilicus
bilaterally. Observe for
contraction of abdominal
muscles and deviation of
the umbilicus toward the
stimulus.
41. Cremasteric (L1, L2). Performed the Performed the Performed the Failed to perform
In a male client, stroke procedures with ease procedures with procedures with the procedure
the inner surface of the minimal supervision maximum
thigh. Observe for
supervision
prompt elevations of the
testis on the ipsilateral
side.
42. Plantar/Babinski (L4, Performed the Performed the Performed the Failed to perform
L5, S1, S2). Extend the procedures with ease procedures with procedures with the procedure
client’s leg with the feet minimal supervision maximum
relaxed. Stoke the lateral
supervision
aspect of the sole from
the heel to the ball of the
foot, curving medially
across the ball. Observe
for flexion of toes.
43. Pathologic Reflexes. Performed the Performed the Performed the Failed to perform
Brudzinski’s sign. Flex procedures with ease procedures with procedures with the procedure
patient’s neck forward minimal supervision maximum
while in recumbent
supervision
[Link]
voluntary flexion of the
knee and pain.
44. Kernig’s sign. Flex Performed the Performed the Performed the Failed to perform
patient’s legs at hip and procedures with ease procedures with procedures with the procedure
knee. Observe neck minimal supervision maximum
flexion and pain. supervision
45. Ankle clonus. Support Performed the Performed the Performed the Failed to perform
client’s knee in a partly procedures with ease procedures with procedures with the procedure
flexed position while minimal supervision maximum
other hands sharply
supervision
dorsiflexes the foot and
maintains it in
dorsiflexion
Properly and skillfully Properly and Properly and Failed to position
positioned the client skillfully positioned skillfully the client
46. Position client
properly the client properly positioned the properly
comfortably.
with less client properly
supervision with maximum
supervision
 Performed the Performed the Performed the Failed to perform
47. Inform client findings procedures with ease procedures with procedures with the procedure
as necessary.
minimal supervision maximum
supervision
48. Wash hands and Washed hands and Washed hands and Washed hands but Washed hands
document findings and documented the some of the details most of the details but
report significant information about of procedure were of the procedure documentation
the procedure and not documented were not was not done
deviation from normal to
properly and documented
the physician
completely

OVERALL SCORE: ________________

Target raw score is 108 out of 144. If raw score is less than 108, repeat the return demonstration.

___________________________________
FACULTY SIGNATURE OVER PRINTED NAME
 OUR LADY OF FATIMA UNIVERSITY
COLLEGE OF NURSING - PAMPANGA

PROGRAM Bachelor of Science in Nursing Student Name

Year and Section
COURSE HEALTH ASSESSMENT Instructor
Date

PROCEDURE : Assessing the Skin

EXPECTED OUTCOME : The student should be able to perform assessing the skin.
ASESSMENT TASK : Return demonstration

Exceptional Good Average Poor

Assessment Dimension SCORE
(3) (2) (1) (0)
Greeted and Performed the two Performed the one Failed to identify
1. Greet and identify the identified client by (2) ways of (1) ways of the client
asking his/her name identifying the the identifying the the
client.
and checking his or client client
her ID band politely
Explained procedure Explained the Explained the Failed to explain
and its purpose to procedure but lack procedure but in procedure and its
2. Explain the procedure the client clearly and some details. an unclear purpose.
completely with manner.
client’s consent
Observed principles Hand washing was Hand washing was
Hand washing
3. Wash hands of medical hand done with minimal done with maximal
was not done
washing error error
Provided privacy Provided privacy Provided privacy
4. Provide for client Failed to provide
during the entire but not in the entire but was observed
privacy privacy
procedure procedure only at times
Properly and skillfully Placed the client Placed client Failed to
positioned the client comfortably and in comfortably and in positioned client
5. Position client
comfortably any preferable any preferable properly and
appropriately and
position with less position with comfortably
comfortably
supervision maximum
supervision
6. Inquire if the client has Performed the Performed the Performed the Failed to perform
any history of skin procedures with ease procedures with procedures with the procedure
allergies and skin minimal supervision maximum
problems supervision
Performed the Performed the Performed the Failed to perform
7. Inspect for skin color
procedures with ease procedures with procedures with the procedure
and uniformity of skin
minimal supervision maximum
color.
supervision
8. Assess edema if Performed the Performed the Performed the Failed to perform
present. Note location, procedures with ease procedures with procedures with the procedure
color, temperature, shape minimal supervision maximum
and the degree to which supervision
the skin remains indented
or pitted when pressed
by a finger.
9. Inspect, palpate and Performed the Performed the Performed the Failed to perform
describe skin lesions. Don procedures with ease procedures with procedures with the procedure
gloves if lesions are open minimal supervision maximum
or draining. Palpate supervision
lesions to determine
shape and texture.
Describe lesions
according to location,
color, configuration, size,
shape, type and structure
10. Observe and palpate Performed the Performed the Performed the Failed to perform
skin moisture. procedures with ease procedures with procedures with the procedure
minimal supervision maximum
supervision
11. Palpate skin Performed the Performed the Performed the Failed to perform
temperature. Compare procedures with ease procedures with procedures with the procedure
the two feet and the two minimal supervision maximum
hands using the back of supervision
the fingers.
12. Note skin turgor Performed the Performed the Performed the Failed to perform
(fullness or elasticity) by procedures with ease procedures with procedures with the procedure
lifting and pinching the minimal supervision maximum
skin on an extremity. supervision
Properly and skillfully Placed the client Placed client Failed to
positioned the client comfortably and in comfortably and in positioned client
13. Position the client
comfortably any preferable any preferable properly and
comfortably after the
position with less position with comfortably
assessment.
supervision maximum
supervision
Performed the Performed the Performed the Failed to perform
14. Inform client findings procedures with ease procedures with procedures with the procedure
if necessary minimal supervision maximum
supervision
15. Wash hands and Washed hands and Washed hands and Washed hands but Washed hands
document findings and documented the some of the details most of the details but
information about of procedure were of the procedure documentation
report significant
the procedure and not documented were not was not done
deviation from normal to
properly and documented
the physician. completely

OVERALL SCORE: ________________

Target raw score is 34 out of 45. If raw score is less than 34, repeat the return demonstration.

___________________________________
FACULTY SIGNATURE OVER PRINTED NAME
 OUR LADY OF FATIMA UNIVERSITY
COLLEGE OF NURSING - PAMPANGA

PROGRAM Bachelor of Science in Nursing Student Name

Year and Section
COURSE HEALTH ASSESSMENT Instructor
Date

PROCEDURE : Assessing the Head, Skull and Face

EXPECTED OUTCOME : The student should be able to perform assessing the head, skull, and face
ASESSMENT TASK : Return demonstration

Exceptional Good Average Poor

Assessment Dimension SCORE
(3) (2) (1) (0)
Greeted and Performed the two Performed the one Failed to identify
1. Greet and identify the identified client by (2) ways of (1) ways of the client
asking his/her name identifying the the identifying the the
client.
and checking his or client client
her ID band politely
Explained procedure Explained the Explained the Failed to explain
and its purpose to procedure but lack procedure but in procedure and its
2. Explain the procedure. the client clearly and some details. an unclear purpose.
completely with manner.
client’s consent
Observed principles Hand washing was Hand washing was
Hand washing
3. Wash hands of medical hand done with minimal done with maximal
was not done
washing error error
Provided privacy Provided privacy Provided privacy
4. Provide for client Failed to provide
during the entire but not in the entire but was observed
privacy privacy
procedure procedure only at times
Properly and skillfully Placed the client Placed client Failed to
positioned the client comfortably and in comfortably and in positioned client
5. Position client
comfortably any preferable any preferable properly and
appropriately and
position with less position with comfortably
comfortably
supervision maximum
supervision
Performed the Performed the Performed the Failed to perform
INSPECTION
procedures with ease procedures with procedures with the procedure
6. Skull, inspect for size,
minimal supervision maximum
shape and symmetry
supervision
Performed the Performed the Performed the Failed to perform
7. Scalp, inspect for
procedures with ease procedures with procedures with the procedure
dandruff, lesions, and
minimal supervision maximum
masses
supervision
Performed the Performed the Performed the Failed to perform
8. Hair, inspect color,
procedures with ease procedures with procedures with the procedure
distribution and nits or
minimal supervision maximum
pediculosis.
supervision
9. Face, note symmetry of Performed the Performed the Performed the Failed to perform
facial movements. Assess procedures with ease procedures with procedures with the procedure
function of the facial minimal supervision maximum
nerve. Ask the client to supervision
smile, frown, elevate and
lower eyebrows, close
eyes tightly, puff the
cheeks and show the
teeth
PALPATION Performed the Performed the Performed the Failed to perform
10. Skull, palpate for procedures with ease procedures with procedures with the procedure
nodules or masses and minimal supervision maximum
depressions supervision
11. Hair, Notice the Performed the Performed the Performed the Failed to perform
texture procedures with ease procedures with procedures with the procedure
minimal supervision maximum
supervision
Performed the Performed the Performed the Failed to perform
12. Face, palpate the
procedures with ease procedures with procedures with the procedure
temporomandibular joint
minimal supervision maximum
for pain and tenderness
supervision
Properly and skillfully Placed the client Placed client Failed to
positioned the client comfortably and in comfortably and in positioned client
13. Position the client
comfortably any preferable any preferable properly and
comfortably after the
position with less position with comfortably
assessment.
supervision maximum
supervision
Performed the Performed the Performed the Failed to perform
14. Inform the client of procedures with ease procedures with procedures with the procedure
findings as necessary minimal supervision maximum
supervision
15. Wash hands and Washed hands and Washed hands and Washed hands but Washed hands
document findings and documented the some of the details most of the details but
information about of procedure were of the procedure documentation
report significant
the procedure and not documented were not was not done
deviation from normal to
properly and documented
the physician. completely

OVERALL SCORE: ________________

Target raw score is 34 out of 45. If raw score is less than 34, repeat the return demonstration.

_____________________________________

FACULTY SIGNATURE OVER PRINTED NAME

 OUR LADY OF FATIMA UNIVERSITY
COLLEGE OF NURSING - PAMPANGA

PROGRAM Bachelor of Science in Nursing Student Name

Year and Section
COURSE HEALTH ASSESSMENT Instructor
Date

PROCEDURE : Assessing the Musculoskeletal System

EXPECTED OUTCOME : The student should be able to perform assessing the musculoskeletal system
ASESSMENT TASK : Return demonstration

Exceptional Good Average Poor

Assessment Dimension SCORE
(3) (2) (1) (0)
Greeted and Performed the two Performed the one Failed to identify
1. Greet and identify identified client by (2) ways of (1) ways of the client
asking his/her name identifying the the identifying the the
client.
and checking his or client client
her ID band politely
Explained procedure Explained the Explained the Failed to explain
and its purpose to procedure but lack procedure but in procedure and its
2. Explain procedures. the client clearly and some details. an unclear purpose.
completely with manner.
client’s consent
Provided privacy Provided privacy Provided privacy
3. Provide for client Failed to provide
during the entire but not in the entire but was observed
privacy privacy
procedure procedure only at times
Properly and skillfully Placed the client Placed client Failed to
positioned the client comfortably and in comfortably and in positioned client
4. Position client
comfortably any preferable any preferable properly and
appropriately and
position with less position with comfortably
comfortably.
supervision maximum
supervision
5. Inquire client Performed the Performed the Performed the Failed to perform
history of presence of procedures with ease procedures with procedures with the procedure
muscle pain and minimal supervision maximum
associated signs and supervision
symptoms, limitations to
movement, loss of
funetion, or previous and
current problems
involving musculoskeletal
system.

6. Inspection: Performed the Performed the Performed the Failed to perform

Observe the client’s procedures with ease procedures with procedures with the procedure
ability to perform minimal supervision maximum
functional task of daily
supervision
living (eg. Performing
personal hygiene, rising
from sitting and standing,
walking up and down
stairs, walking on a level
surface). Note any pain
the client experiences
while performing
functions are being
examined.

7. Extremities: Performed the Performed the Performed the Failed to perform

Examine the arms and procedures with ease procedures with procedures with the procedure
legs. Note the size, minimal supervision maximum
symmetry, muscle mass,
supervision
and deformities.
8. Spine: Assess for Performed the Performed the Performed the Failed to perform
range of motion (ie, procedures with ease procedures with procedures with the procedure
flexion, extension, lateral minimal supervision maximum
flexion, and rotation) and
supervision
lateral or antero-posterior
curvature

9. Joints: Assess all Performed the Performed the Performed the Failed to perform
major joints, noting any procedures with ease procedures with procedures with the procedure
limitations to active range minimal supervision maximum
motion, swelling or
supervision
redness.

Performed the Performed the Performed the Failed to perform

10. Neck: Assess
flexion, extension and procedures with ease procedures with procedures with the procedure
lateral rotation minimal supervision maximum
supervision
Performed the Performed the Performed the Failed to perform
11. Shoulders:
Assess flexion, extension procedures with ease procedures with procedures with the procedure
and rotation. minimal supervision maximum
supervision
Performed the Performed the Performed the Failed to perform
12. Elbows: Assess
flexion, extension, procedures with ease procedures with procedures with the procedure
supination, and pronation minimal supervision maximum
supervision
13. Wrists: Assess Performed the Performed the Performed the Failed to perform
flexion, extension and procedures with ease procedures with procedures with the procedure
ulnar and radial minimal supervision maximum
deviation.
supervision
Performed the Performed the Performed the Failed to perform
14. Fingers: Assess
flexion, extension procedures with ease procedures with procedures with the procedure
abduction and adduction minimal supervision maximum
supervision
Performed the Performed the Performed the Failed to perform
15. Hips: Assess
flexion, extension and procedures with ease procedures with procedures with the procedure
rotation minimal supervision maximum
supervision
Performed the Performed the Performed the Failed to perform
16. Knees: Assess procedures with ease procedures with procedures with the procedure
flexion, extension minimal supervision maximum
supervision
17. Ankles: Assess Performed the Performed the Performed the Failed to perform
dorsiflexion, plantar procedures with ease procedures with procedures with the procedure
flexion, inversion, and minimal supervision maximum
eversion
supervision
Performed the Performed the Performed the Failed to perform
18. Toes: Assess flexion,
extension abduction and procedures with ease procedures with procedures with the procedure
adduction minimal supervision maximum
supervision
19. Palpation: Performed the Performed the Performed the Failed to perform
Joints of the neck and procedures with ease procedures with procedures with the procedure
upper and lower minimal supervision maximum
extremities. Palpate while
supervision
noting tenderness,
swelling, temperature,
limitations to passive
range of motion and
crepitation.
20. Muscles: Palpate to Performed the Performed the Performed the Failed to perform
assess size, tone and any procedures with ease procedures with procedures with the procedure
tenderness minimal supervision maximum
supervision
21. Spine: Palpate noting Performed the Performed the Performed the Failed to perform
any bone deformities and procedures with ease procedures with procedures with the procedure
crepitation. minimal supervision maximum
supervision
22. Percussion: Directly Performed the Performed the Performed the Failed to perform
percuss the spine from procedures with ease procedures with procedures with the procedure
the cervical to lumbar minimal supervision maximum
region, using the ulnar supervision
surface of the list. Note
any pain or tenderness.

Properly and skillfully Placed the client Placed client Failed to

23. Position client positioned the client comfortably and in comfortably and in positioned client
comfortably after the comfortably any preferable any preferable properly and
assessment position with less position with comfortably
supervision maximum
supervision
Performed the Performed the Performed the Failed to perform
24. Inform client findings
procedures with ease procedures with procedures with the procedure
as necessary
minimal supervision maximum
supervision
25. Wash hands and Washed hands and Washed hands and Washed hands but Washed hands
document findings and documented the some of the details most of the details but
report significant information about of procedure were of the procedure documentation
the procedure and not documented were not was not done
deviation from normal to
properly and documented
the physician.
completely

OVERALL SCORE: ________________

Target raw score is 56 out of 75. If raw score is less than 56, repeat the return demonstration.

_____________________________________

FACULTY SIGNATURE OVER PRINTED NAME

 OUR LADY OF FATIMA UNIVERSITY
COLLEGE OF NURSING - PAMPANGA

PROGRAM Bachelor of Science in Nursing Student Name

Year and Section
COURSE HEALTH ASSESSMENT Instructor
Date

PROCEDURE : Assessing the Eyes, Nose , Mouth and Throat

EXPECTED OUTCOME : The student should be able to perform assessing the eyes, nose, mouth and
throat
ASESSMENT TASK : Return demonstration

Exceptional Good Average Poor

Assessment Dimension SCORE
(3) (2) (1) (0)
Gathered materials Gathered materials Gathered Failed to gather
1. Prepare all the needed with little time materials with all the materials
equipment needed preparation more time needed
preparation
Greeted and Performed the two Performed the one Failed to identify
2. Greet and identify identified client by (2) ways of (1) ways of the client
asking his/her name identifying the the identifying the the
client.
and checking his or client client
her ID band politely
Explained procedure Explained the Explained the Failed to explain
and its purpose to procedure but lack procedure but in procedure and its
3. Explain procedures. the client clearly and some details. an unclear purpose.
completely with manner.
client’s consent
Provided privacy Provided privacy Provided privacy
4. Provide for client Failed to provide
during the entire but not in the entire but was observed
privacy privacy
procedure procedure only at times
Properly and skillfully Placed the client Placed client Failed to
positioned the client comfortably and in comfortably and in positioned client
5. Position client
comfortably any preferable any preferable properly and
appropriately and
position with less position with comfortably
comfortably.
supervision maximum
supervision
EYES
6. Inquire client’s history Performed the Performed the Performed the Failed to perform
of eye diseases, injury or procedures with ease procedures with procedures with the procedure
surgery, family history of minimal supervision maximum
diabetes; current supervision
symptoms of eye
problems; and use of eye
glasses, contact lenses or
medications.
Performed the Performed the Performed the Failed to perform
7. Inspection of palpebral
procedures with ease procedures with procedures with the procedure
tissues. Assess for
minimal supervision maximum
symmetry and width.
supervision
8. Inspect for the Performed the Performed the Performed the Failed to perform
lid margins, observe for procedures with ease procedures with procedures with the procedure
scaling, secretions, minimal supervision maximum
erythema and position of supervision
lashes

9. Inspect for color Performed the Performed the Performed the Failed to perform
and congestion of procedures with ease procedures with procedures with the procedure
conjunctivae. minimal supervision maximum
supervision

10. Observe the color of Performed the Performed the Performed the Failed to perform
sclerae and irises procedures with ease procedures with procedures with the procedure
 minimal supervision maximum
supervision
11. Observe the size, Performed the Performed the Performed the Failed to perform
shape, symmetry, and procedures with ease procedures with procedures with the procedure
reaction to light and minimal supervision maximum
accommodation of the supervision
pupils
Performed the Performed the Performed the Failed to perform
12. Assess the six ocular
procedures with ease procedures with procedures with the procedure
movement of muscles
minimal supervision maximum
and nerves of the eye.
supervision
13. Perform a Performed the Performed the Performed the Failed to perform
fundoscopic examination procedures with ease procedures with procedures with the procedure
of the inner eye with the minimal supervision maximum
use of an opthalmoscope supervision
and locate the red reflex.
14. Check the Performed the Performed the Performed the Failed to perform
transparency of the procedures with ease procedures with procedures with the procedure
anterior and posterior minimal supervision maximum
chamber, cornea and supervision
lens.
Performed the Performed the Performed the Failed to perform
15. Examine the retina
procedures with ease procedures with procedures with the procedure
optic disc, macula, and
minimal supervision maximum
blood vessels.
supervision
16. Palpate the upper lid. Performed the Performed the Performed the Failed to perform
Evaluate strength by procedures with ease procedures with procedures with the procedure
attempting to open the minimal supervision maximum
client’s closed lid against supervision
her resistance
Performed the Performed the Performed the Failed to perform
17. Assess tenderness
procedures with ease procedures with procedures with the procedure
and tension of the
minimal supervision maximum
eyeballs.
supervision
18. Test the visual acuity Performed the Performed the Performed the Failed to perform
with a Snellen chart. Test procedures with ease procedures with procedures with the procedure
a client wearing minimal supervision maximum
corrective lenses with supervision
and without the lenses.
19. Test visual peripheral Performed the Performed the Performed the Failed to perform
fields using the cover and procedures with ease procedures with procedures with the procedure
uncover test and note for minimal supervision maximum
nystagmus and supervision
convergence
20. Perform functional Performed the Performed the Performed the Failed to perform
vision test using light procedures with ease procedures with procedures with the procedure
perception hand minimal supervision maximum
movement and counting supervision
fingers.
EARS
21. Inquire client’s Performed the Performed the Performed the Failed to perform
family history of hearing procedures with ease procedures with procedures with the procedure
problems or loss; minimal supervision maximum
presence of any ear supervision
problems; medication
history and signs and
symptoms of ear
problems.

Performed the Performed the Performed the Failed to perform

22. Inspect color,
procedures with ease procedures with procedures with the procedure
symmetry of size and
minimal supervision maximum
position of auricles.
supervision
23. Inspect for discharges, Performed the Performed the Performed the Failed to perform
impacted cerumen and procedures with ease procedures with procedures with the procedure
inflammation in the minimal supervision maximum
external ear canal using supervision
an otoscope.
Performed the Performed the Performed the Failed to perform
24. Inspect for color and
procedures with ease procedures with procedures with the procedure
gloss of the tympanic
minimal supervision maximum
membrane
supervision
25. Palpate and examine Performed the Performed the Performed the Failed to perform
the pinna for tenderness, procedures with ease procedures with procedures with the procedure
consistency of cartilage, minimal supervision maximum
swelling and pain supervision
Performed the Performed the Performed the Failed to perform
26. Assess gross hearing procedures with ease procedures with procedures with the procedure
acuity test. minimal supervision maximum
supervision
Performed the Performed the Performed the Failed to perform
27. Assess client’s
procedures with ease procedures with procedures with the procedure
response to normal voice
minimal supervision maximum
tones.
supervision
Performed the Performed the Performed the Failed to perform
28. Perform watch tick procedures with ease procedures with procedures with the procedure
test minimal supervision maximum
supervision
Performed the Performed the Performed the Failed to perform
29. Perform Weber’s test
procedures with ease procedures with procedures with the procedure
to assess bone
minimal supervision maximum
conduction
supervision
30. Conduct the Rinne’s Performed the Performed the Performed the Failed to perform
test to compare air procedures with ease procedures with procedures with the procedure
conduction to bone minimal supervision maximum
conduction. supervision
NOSE AND SINUSES
31. Inquire client’s history Performed the Performed the Performed the Failed to perform
of allergies and difficulty procedures with ease procedures with procedures with the procedure
breathing through the minimal supervision maximum
nose, sinus infections, supervision
injuries to nose or face,
nose bleeds, any
medication taken, any
changes in sense of smell.
32. Palpate the external Performed the Performed the Performed the Failed to perform
nose. Inspect for any procedures with ease procedures with procedures with the procedure
deviations in shape, size minimal supervision maximum
and color and flaring or supervision
discharges from the
nares.
33. Assess the interior Performed the Performed the Performed the Failed to perform
structure of nasal passage procedures with ease procedures with procedures with the procedure
way using nasal speculum. minimal supervision maximum
Note for nasal septum for supervision
position, bleeding or
perforation; mucous
membranes for hydration
and color and nasal
turbinates for color and
swelling.
34. Palpate for external Performed the Performed the Performed the Failed to perform
nose. Determine any procedures with ease procedures with procedures with the procedure
areas of tenderness, minimal supervision maximum
masses and displacement supervision
of bone and cartilage.
Performed the Performed the Performed the Failed to perform
35. Palpate the maxillary
procedures with ease procedures with procedures with the procedure
and frontal sinuses and
minimal supervision maximum
tenderness
supervision
MOUTH AND
OROPHARYNX
36. Inquire client’s history Performed the Performed the Performed the Failed to perform
of mouth, gums and procedures with ease procedures with procedures with the procedure
dental problems minimal supervision maximum
supervision
37. Inspect lips and Performed the Performed the Performed the Failed to perform
observe for the color, procedures with ease procedures with procedures with the procedure
moisture, pigmentation, minimal supervision maximum
masses, ulcerations and supervision
fissures
38. Inspect the teeth. Performed the Performed the Performed the Failed to perform
Note the number, procedures with ease procedures with procedures with the procedure
arrangement and general minimal supervision maximum
condition. supervision
39. Inspect the Performed the Performed the Performed the Failed to perform
gingivae and assess color, procedures with ease procedures with procedures with the procedure
discharges, edema, minimal supervision maximum
bleeding and retraction. supervision

40. Inspect the Performed the Performed the Performed the Failed to perform
buccal mucosa and assess procedures with ease procedures with procedures with the procedure
color, vesicles, ulcerations minimal supervision maximum
and masses supervision

41. Inspect for the Performed the Performed the Performed the Failed to perform
pharynx. Note procedures with ease procedures with procedures with the procedure
inflammation, exudates minimal supervision maximum
and masses supervision

Performed the Performed the Performed the Failed to perform

42. Assess for the
procedures with ease procedures with procedures with the procedure
position and color of the
minimal supervision maximum
tongue.
supervision
Performed the Performed the Performed the Failed to perform
43. Assess function of procedures with ease procedures with procedures with the procedure
glossopharyngeal nerve. minimal supervision maximum
supervision
Performed the Performed the Performed the Failed to perform
44. Assess function of procedures with ease procedures with procedures with the procedure
the hypoglossal nerve. minimal supervision maximum
supervision
Performed the Performed the Performed the Failed to perform
45. Inspect for any procedures with ease procedures with procedures with the procedure
swelling or redness. minimal supervision maximum
supervision
46. Inspect the hard Performed the Performed the Performed the Failed to perform
and soft palate for color, procedures with ease procedures with procedures with the procedure
shape, texture and minimal supervision maximum
presence of bony supervision
prominences.

47. Inspect for position Performed the Performed the Performed the Failed to perform
and mobility of the uvula procedures with ease procedures with procedures with the procedure
while examining the minimal supervision maximum
palate. Ask the patient to supervision
say “ah” so that the soft
palate rises.
48. Inspect for the color Performed the Performed the Performed the Failed to perform
and texture of procedures with ease procedures with procedures with the procedure
oropharynx using tongue minimal supervision maximum
depressor. Use penlight supervision
or illumination
Performed the Performed the Performed the Failed to perform
49. Inspect for the color,
procedures with ease procedures with procedures with the procedure
discharge and size of the
minimal supervision maximum
tonsil.
supervision
50. Palpate for cervical Performed the Performed the Performed the Failed to perform
nodes and salivary glands procedures with ease procedures with procedures with the procedure
for enlargement and minimal supervision maximum
tenderness. supervision
Performed the Performed the Performed the Failed to perform
51. Inspect for the
procedures with ease procedures with procedures with the procedure
trachea and note any
minimal supervision maximum
deviation from midline.
supervision
Performed the Performed the Performed the Failed to perform
52. Palpate the thyroid
procedures with ease procedures with procedures with the procedure
for nodules, masses or
minimal supervision maximum
any irregularities.
supervision
Performed the Performed the Performed the Failed to perform
53. Note for the
procedures with ease procedures with procedures with the procedure
amplitude and symmetry
minimal supervision maximum
of the carotid arteries.
supervision
Performed the Performed the Performed the Failed to perform
54. Listen for bruits over procedures with ease procedures with procedures with the procedure
carotid arteries. minimal supervision maximum
supervision
NECK
55. Inquire client’s history Performed the Performed the Performed the Failed to perform
of any problems with procedures with ease procedures with procedures with the procedure
neck lumps, neck pain or minimal supervision maximum
stiffness, any previous supervision
diagnoses of thyroid
problems and any other
treatment provided.
56. Inspect neck muscles Performed the Performed the Performed the Failed to perform
(sternocleidomastoid and procedures with ease procedures with procedures with the procedure
trapezius) for any minimal supervision maximum
abnormal swelling or supervision
masses, symmetry and
range of motion and
strength.
57. Inspect for the thyroid Performed the Performed the Performed the Failed to perform
glands symmetry and procedures with ease procedures with procedures with the procedure
masses. Ask the client to minimal supervision maximum
hyper extend the head supervision
and swallow while
observing the movement
of the thyroid and cricoid
cartilage as client swallow
and note is swallowing
causes as bulging of the
gland.
Performed the Performed the Performed the Failed to perform
58. Inspect for the jugular procedures with ease procedures with procedures with the procedure
veins. Note distention. minimal supervision maximum
supervision
Performed the Performed the Performed the Failed to perform
59. Palpate for
procedures with ease procedures with procedures with the procedure
lymphnodes for
minimal supervision maximum
tenderness and swelling.
supervision
Performed the Performed the Performed the Failed to perform
60. Palpate for lateral procedures with ease procedures with procedures with the procedure
deviation of the trachea. minimal supervision maximum
supervision
61. Palpate thyroid gland Performed the Performed the Performed the Failed to perform
for smoothness, procedures with ease procedures with procedures with the procedure
enlargement, masses or minimal supervision maximum
nodules. supervision
Properly and skillfully Placed the client Placed client Failed to
positioned the client comfortably and in comfortably and in positioned client
62. Place the client in a comfortably any preferable any preferable properly and
comfortable position position with less position with comfortably
supervision maximum
supervision
 Performed the Performed the Performed the Failed to perform
63. Inform client findings procedures with ease procedures with procedures with the procedure
as necessary minimal supervision maximum
supervision
64. Wash hands and Washed hands and Washed hands and Washed hands but Washed hands
document findings and documented the some of the details most of the details but
information about of procedure were of the procedure documentation
report significant
the procedure and not documented were not was not done
deviation from normal to
properly and documented
the physician. completely

OVERALL SCORE: ________________

Target raw score is 144 out of 192. If raw score is less than 144, repeat the return demonstration.

_____________________________________

FACULTY SIGNATURE OVER PRINTED NAME

 OUR LADY OF FATIMA UNIVERSITY
COLLEGE OF NURSING - PAMPANGA

PROGRAM Bachelor of Science in Nursing Student Name

Year and Section
COURSE HEALTH ASSESSMENT Instructor
Date

PROCEDURE : Assessing the Peripheral Vascular System

EXPECTED OUTCOME : The student should be able to perform assessing the peripheral vascular
system
ASESSMENT TASK : Return demonstration
Exceptional Good Average Poor
Assessment Dimension SCORE
(3) (2) (1) (0)
Greeted and Performed the two Performed the one Failed to identify
identified client by (2) ways of (1) ways of the client
1. Greet and identify
asking his/her name identifying the the identifying the the
client.
and checking his or client client
her ID band politely
Explained procedure Explained the Explained the Failed to explain
and its purpose to procedure but lack procedure but in procedure and its
2. Explain procedures. the client clearly and some details. an unclear purpose.
completely with manner.
client’s consent
Provided privacy Provided privacy Provided privacy
3. Provide for client Failed to provide
during the entire but not in the entire but was observed
privacy privacy
procedure procedure only at times
Properly and skillfully Placed the client Placed client Failed to
positioned the client comfortably and in comfortably and in positioned client
4. Position client
comfortably any preferable any preferable properly and
appropriately and
position with less position with comfortably
comfortably.
supervision maximum
supervision
Observed principles Hand washing was Hand washing was
Hand washing
5. Wash hands of medical hand done with minimal done with maximal
was not done
washing error error
6. Inquire client Performed the Performed the Performed the Failed to perform
history of heart disorders, procedures with ease procedures with procedures with the procedure
varicosities, arterial minimal supervision maximum
diseases and supervision
hypertension; lifestyle
habits such as exercise
patterns, activity patterns
and tolerance, smoking
and use of alcohol.
7. Inspection. Performed the Performed the Performed the Failed to perform
Peripheral views. Inspect procedures with ease procedures with procedures with the procedure
peripheral views in the minimal supervision maximum
arms and the legs for the
supervision
presence of superficial
veins when limbs are
dependent and when
limbs are elevated.

8. Peripheral Performed the Performed the Performed the Failed to perform

perfusion. Inspect the procedures with ease procedures with procedures with the procedure
skin of the hands and feet minimal supervision maximum
for color, edema, texture supervision
and skin changes

9. Palpation. Peripheral Performed the Performed the Performed the Failed to perform
pulses. Palpate peripheral procedures with ease procedures with procedures with the procedure
pulses on both sides of minimal supervision maximum
the client’s body supervision
individually,simultaneousl
y and systematically to
determine the symmetry
of pulses volume and
pulsations
10. Peripheral veins. Performed the Performed the Performed the Failed to perform
Assess peripheral leg procedures with ease procedures with procedures with the procedure
veins for signs of minimal supervision maximum
phlebitis. Note supervision
tenderness on palpation
and pain in calf muscles
with forceful dorsiflexion
of both the foot. ((+)
Homan’s Sign) and
warmth to touch.
11. Peripheral perfusion. Performed the Performed the Performed the Failed to perform
Assess for adequacy of procedures with ease procedures with procedures with the procedure
arterial blood flow minimal supervision maximum
supervision
12. Buerger’s test Performed the Performed the Performed the Failed to perform
(Arterial adequacy Test) procedures with ease procedures with procedures with the procedure
Ask the client to raise one minimal supervision maximum
leg or one arm at about
supervision
30cm. (1 feet) above
heart level, move the foot
or hand briskly up and
down for about 1 minute
and then sit up and
dangle the leg or arm.
Original color return in 10
seconds; veins in feet and
hands fill in about 15
seconds.

13. Capillary Refill test. Performed the Performed the Performed the Failed to perform
Squeeze client’s fingernail procedures with ease procedures with procedures with the procedure
and toenail between your minimal supervision maximum
fingers sufficiently to
supervision
cause blanching. Note
immediate return of
color.

Properly and skillfully Placed the client Placed client Failed to

14. Position client positioned the client comfortably and in comfortably and in positioned client
comfortably after the comfortably any preferable any preferable properly and
assessment. position with less position with comfortably
supervision maximum
supervision
Performed the Performed the Performed the Failed to perform
15. Inform client findings procedures with ease procedures with procedures with the procedure
as necessary
minimal supervision maximum
supervision
16. Wash hands and Washed hands and Washed hands and Washed hands but Washed hands
document findings and documented the some of the details most of the details but
report significant information about of procedure were of the procedure documentation
deviation from normal to the procedure and not documented were not was not done
the physician. properly and documented
completely

OVERALL SCORE: ________________

Target raw score is 36 out of 48. If raw score is less than 36, repeat the return demonstration.

_____________________________________

FACULTY SIGNATURE OVER PRINTED NAME

 OUR LADY OF FATIMA UNIVERSITY
COLLEGE OF NURSING - PAMPANGA

PROGRAM Bachelor of Science in Nursing Student Name

Year and Section
COURSE HEALTH ASSESSMENT Instructor
Date

PROCEDURE : Assessing the Thorax, Heart, Breast, and Axillae

EXPECTED OUTCOME : The student should be able to perform assessing the thorax, heart, breast,
axillae
ASESSMENT TASK : Return demonstration

Exceptional Good Average Poor

Assessment Dimension SCORE
(3) (2) (1) (0)
1. Prepare the materials Gathered materials Gathered materials Gathered Failed to gather
needed with little time materials with all the materials
preparation more time needed
preparation
2. Greet and identify Greeted and Performed the two Performed the one Failed to identify
client. identified client by (2) ways of (1) ways of the client
asking his/her name identifying the the identifying the the
and checking his or client client
her ID band politely
3. Explain procedures. Explained procedure Explained the Explained the Failed to explain
and its purpose to procedure but lack procedure but in procedure and its
the client clearly and some details. an unclear purpose.
completely with manner.
client’s consent
4. Provide for client Provided privacy Provided privacy Provided privacy Failed to provide
privacy during the entire but not in the entire but was observed privacy
procedure procedure only at times
5. Position client Properly and skillfully Placed the client Placed client Failed to
appropriately. Drape the positioned the client comfortably and in comfortably and in positioned client
anterior chest when it is comfortably any preferable any preferable properly and
not being examined. position with less position with comfortably
supervision maximum
supervision
6. Posterior thorax: Performed the Performed the Performed the Failed to perform
Inquire client history of procedures with ease procedures with procedures with the procedure
heart and lung diseases; minimal supervision maximum
allergies, lifestyle habits, supervision
any medications being
taken or current
problems
7. Inspect for the spinal Performed the Performed the Performed the Failed to perform
alignment for deformities procedures with ease procedures with procedures with the procedure
minimal supervision maximum
supervision
8. Inspect for symmetry Performed the Performed the Performed the Failed to perform
of the thorax from procedures with ease procedures with procedures with the procedure
posterior and lateral minimal supervision maximum
views. Compare the supervision
anteroposterior diameter
to the transverse
diameter.
9. Palpate all chest areas Performed the Performed the Performed the Failed to perform
for bulges, tenderness or procedures with ease procedures with procedures with the procedure
abnormal movement. minimal supervision maximum
supervision
10. Assess respiratory Performed the Performed the Performed the Failed to perform
excursion notices the procedures with ease procedures with procedures with the procedure
distance that your minimal supervision maximum
thumbs part. supervision
11. Palpate for tactile Performed the Performed the Performed the Failed to perform
fremitus using the ulnar procedures with ease procedures with procedures with the procedure
surface of the hand. Ask minimal supervision maximum
client to say ninety nine supervision
or tres tres.
12. Percuss for Performed the Performed the Performed the Failed to perform
diaphragmatic excursion procedures with ease procedures with procedures with the procedure
on complete exhalation minimal supervision maximum
and inhalation, marking supervision
points where resonance
changes to dullness.
Detect, compare and
localize abnormal
percussion sounds.
13. Using stethoscope, Performed the Performed the Performed the Failed to perform
listen over the same procedures with ease procedures with procedures with the procedure
areas and in the same minimal supervision maximum
pattern as for percussion supervision
comparing from side to
side and moving from
apices to lung bases.
Performed the Performed the Performed the Failed to perform
14. Inspect the anterior
procedures with ease procedures with procedures with the procedure
thorax for structural
minimal supervision maximum
deformities.
supervision
Performed the Performed the Performed the Failed to perform
15. Assess the width of
procedures with ease procedures with procedures with the procedure
the costal angle of
minimal supervision maximum
anterior thorax.
supervision
16. Notice the rate and Performed the Performed the Performed the Failed to perform
rhythm of breathing. procedures with ease procedures with procedures with the procedure
Observe for respiratory minimal supervision maximum
abnormalities (eg. Bulging supervision
or retraction of
intercostal space and use
of accessory muscles) and
asymmetry.
17. Palpate for respiratory Performed the Performed the Performed the Failed to perform
excursion and tactile procedures with ease procedures with procedures with the procedure
fremitus in the same minimal supervision maximum
manner as for the supervision
posterior chest.
18. Percuss the anterior Performed the Performed the Performed the Failed to perform
chest systematically. procedures with ease procedures with procedures with the procedure
Begin above the clavicles minimal supervision maximum
in the supraclavicular supervision
space and proceed
downward to the
diaphragm. Compare one
side of the lungs to the
other. Displace female
breast for proper
examination.
19. Auscultate the Performed the Performed the Performed the Failed to perform
anterior chest over the procedures with ease procedures with procedures with the procedure
same areas and in the minimal supervision maximum
same manner as for supervision
percussion. Notice the
distribution of vesicular
and bronchovesicular and
broncovesicular sounds.
20. Heart: Inspect Performed the Performed the Performed the Failed to perform
precordium, look for lifts, procedures with ease procedures with procedures with the procedure
heaves, thrust or minimal supervision maximum
pulsations supervision

Performed the Performed the Performed the Failed to perform

21. Inspect for apical
procedures with ease procedures with procedures with the procedure
impulses. Observe for
minimal supervision maximum
visible pulsations.
supervision
22. Using palms, Performed the Performed the Performed the Failed to perform
palpate all auscultatory procedures with ease procedures with procedures with the procedure
areas, note for vibrations minimal supervision maximum
and thrills. supervision

Performed the Performed the Performed the Failed to perform

23. Locate and assess the
procedures with ease procedures with procedures with the procedure
apical impulses, rate and
minimal supervision maximum
strength pulsations.
supervision
24. Percuss the heart’s Performed the Performed the Performed the Failed to perform
borders in the 3rd – 5th procedures with ease procedures with procedures with the procedure
LICS, noting areas of minimal supervision maximum
cardiac dullness. supervision
25. Auscultate the aortic Performed the Performed the Performed the Failed to perform
area is in the 2nd ICS to procedures with ease procedures with procedures with the procedure
the right of the sternum, minimal supervision maximum
listen with the supervision
stethoscope’s diaphragm
(best for high pitched
sound) and bell (best for
low pitched sounds).
26. Auscultate the Performed the Performed the Performed the Failed to perform
pulmonic area in the 2nd procedures with ease procedures with procedures with the procedure
ICS to the left of the minimal supervision maximum
sternum supervision
27. Auscultate the Performed the Performed the Performed the Failed to perform
tricuspid area in the 4th procedures with ease procedures with procedures with the procedure
ICS along the left of the minimal supervision maximum
sternum supervision
28. The apical/mitral area Performed the Performed the Performed the Failed to perform
or point of maximal procedures with ease procedures with procedures with the procedure
impulse (PMI) is on the minimal supervision maximum
5th ICS at the left supervision
midclavicular line, 2-3
inches from the tricuspid
area.
29. Identify S1 and S2 Performed the Performed the Performed the Failed to perform
(lub-dub sound). S1 is the procedures with ease procedures with procedures with the procedure
loudest n the mitral area minimal supervision maximum
and S2 is the loudest in supervision
the aortic and mitral area.
Performed the Performed the Performed the Failed to perform
30. Determine the heart
procedures with ease procedures with procedures with the procedure
rate and rhythm. Note
minimal supervision maximum
any adventitious sound.
supervision
31. Breast and axillae. Performed the Performed the Performed the Failed to perform
Inquire client’s history of procedures with ease procedures with procedures with the procedure
breast cancer, any minimal supervision maximum
medication being taken, supervision
menstrual cycle (woman)
previous or current breast
problems such as nipple
discharges, masses,
tenderness or pain.
32. Inspect the breast Performed the Performed the Performed the Failed to perform
with client sitting, inspect procedures with ease procedures with procedures with the procedure
for size, symmetry and minimal supervision maximum
contour or shape. supervision
33. Inspect breast Performed the Performed the Performed the Failed to perform
skin for discoloration or procedures with ease procedures with procedures with the procedure
hyperpigmentation, minimal supervision maximum
retraction or dimpling supervision
and swelling or edema.

34. Inspect the Performed the Performed the Performed the Failed to perform
areola, size, shape, procedures with ease procedures with procedures with the procedure
symmetry, color, surface minimal supervision maximum
characteristics and any supervision
masses or lesions.

35. Inspect the Performed the Performed the Performed the Failed to perform
nipple’s size, shape, procedures with ease procedures with procedures with the procedure
position, color, discharge, minimal supervision maximum
and lesions. supervision

36. Palpate the breast of Performed the Performed the Performed the Failed to perform
the client while sitting for procedures with ease procedures with procedures with the procedure
masses and tenderness minimal supervision maximum
using concentric circle supervision
pattern. Start at one
point and move
systematically to the end
point to ensure that all
breast surfaces are
assessed. Pay particular
attention to the upper
outer quadrant area and
the tail of Spence.
37. Palpate the areola Performed the Performed the Performed the Failed to perform
and nipple for masses. procedures with ease procedures with procedures with the procedure
Compare each nipple to minimal supervision maximum
determine presence of supervision
discharges. Note
discharges for amount,
color, consistency and
odor.
38. Palpate the axillary, Performed the Performed the Performed the Failed to perform
supraclavicular lymph procedures with ease procedures with procedures with the procedure
nodes. With client sitting, minimal supervision maximum
and arms abducted and supervision
supported on the nurse’s
forearm, palpate
clavicular lymph nodes,
use the flat surfaces of all
fingertips to palpate the
four areas of the axilla.
a. Muscular pectoralis
major along the anterior
axillary line
b. Thoracic wall in the
mid axillary area
c. Upper part of the
humerus
d. Anterior edge of the
latissimus dorsi muscle
along the posterior
axillary line.
Placed client
Placed the client
comfortably and in Failed to
39. Position the client Properly and skillfully comfortably and in
any preferable positioned client
comfortably in bed. positioned the client any preferable
position with properly and
comfortably position with less
maximum comfortably
supervision
supervision
Performed the Performed the Performed the Failed to perform
40. Inform client of
procedures with ease procedures with procedures with the procedure
findings as necessary.
minimal supervision maximum
supervision
41. Wash hands and Washed hands and Washed hands and Washed hands but Washed hands
document findings and documented the some of the details most of the details but
report significant information about of procedure were of the procedure documentation
deviation from normal to the procedure and not documented were not was not done
the physician. properly and documented
completely

OVERALL SCORE: ________________

Target raw score is 92 out of 123. If raw score is less than 92, repeat the return demonstration.

_____________________________________
FACULTY SIGNATURE OVER PRINTED NAME
 OUR LADY OF FATIMA UNIVERSITY
COLLEGE OF NURSING - PAMPANGA

PROGRAM Bachelor of Science in Nursing Student Name

Year and Section
COURSE HEALTH ASSESSMENT Instructor
Date

PROCEDURE : Assessing the Female and Male Genitalia and Inguinal Area
EXPECTED OUTCOME : The student should be able to perform assessing the female and male
genitalia and inguinal area
ASESSMENT TASK : Return demonstration

Exceptional Good Average Poor

Assessment Dimension SCORE
(3) (2) (1) (0)
1. Prepare Gathered materials Gathered materials Gathered Failed to gather
equipment: needed with little time materials with all the materials
Female: gloves, drape, preparation more time needed
supplemental lightning preparation

Observed principles Hand washing was Hand washing was

2. Wash Hands. Hand washing
of medical hand done with minimal done with maximal
was not done
washing error error
Greeted and Performed the two Performed the one Failed to identify
3. Greet and identify identified client by (2) ways of (1) ways of the client
client. asking his/her name identifying the the identifying the the
and checking his or client client
her ID band politely
Explained procedure Explained the Explained the Failed to explain
and its purpose to procedure but lack procedure but in procedure and its
4. Explain the procedure
the client clearly and some details. an unclear purpose.
completely with manner.
client’s consent
5. Provide for client’s Provided privacy Provided privacy Provided privacy
Failed to provide
privacy. during the entire but not in the entire but was observed
privacy
procedure procedure only at times
Properly and skillfully Placed the client Placed client Failed to
positioned the client comfortably and in comfortably and in positioned client
6. Position and drape comfortably any preferable any preferable properly and
client appropriately.
position with less position with comfortably
supervision maximum
supervision
7. Done gloves. Gloving was done Gloving was done Gloving was done Gloving was not
properly and skillfully with minimal error with maximal error done
FEMALE GENITALIA
8. Inquire client Performed the Performed the Performed the Failed to perform
history of onset of procedures with ease procedures with procedures with the procedure
menstruation, last minimal supervision maximum
menstrual period (LMP), supervision
regularity of cycle,
sexually transmitted
diseases, previous and
current problems on
reproduction and urinary
system.

9. Inspection and Performed the Performed the Performed the Failed to perform
palpation. These procedures with ease procedures with procedures with the procedure
examinations are minimal supervision maximum
performed almost supervision
simultaneously. Place the
client in lithotomy
position and drape her
properly.

10. External genitalia. Performed the Performed the Performed the Failed to perform
Assess pubic hair procedures with ease procedures with procedures with the procedure
distribution. Note any nits minimal supervision maximum
and lice. Inspect the labia supervision
majora, mons pubis, and
perineum. Note skin color
and integrity.

11. Internal genitalia. Performed the Performed the Performed the Failed to perform
Separate the labia procedures with ease procedures with procedures with the procedure
majora, and inspect the minimal supervision maximum
clitoris, urethral meatus, supervision
and vaginal opening.
Note abnormal color,
ulcerations, edema,
nodules or discharge.

12. Inguinal lymph nodes. Performed the Performed the Performed the Failed to perform
Use the pads of the procedures with ease procedures with procedures with the procedure
fingers in a rotary motion, minimal supervision maximum
noting any enlargement supervision
or tenderness.

MALE GENITALIA
13. Inquire client Performed the Performed the Performed the Failed to perform
history of voiding procedures with ease procedures with procedures with the procedure
patterns and any minimal supervision maximum
changes, bladder control, supervision
urinary incontinence,
frequency urgency,
abdominal pain, any
symptoms of sexually
transmitted disease; any
swelling that could
indicate presence of
hernia, family history of
nephritis, malignancy of
the prostate or kidney.

14. Inspection. Pubic Performed the Performed the Performed the Failed to perform
hair. Assess distribution, procedures with ease procedures with procedures with the procedure
and note any nits or lice. minimal supervision maximum
supervision
15. Penis. Retract the Performed the Performed the Performed the Failed to perform
foreskin, if present. Note procedures with ease procedures with procedures with the procedure
any ulcerations, masses, minimal supervision maximum
or scaring on the glans supervision
penis. Inspect the
urethral meatus for
location, lesions, and
discharge.

16. Scrotum. Inspect Performed the Performed the Performed the Failed to perform
anterior and posterior procedures with ease procedures with procedures with the procedure
aspects, assessing size, minimal supervision maximum
contour, and symmetry. supervision
Note ulcerations, masses,
redness, or swelling.

17. Inguinal areas. Performed the Performed the Performed the Failed to perform
Look for bulges, with or procedures with ease procedures with procedures with the procedure
without the client bearing minimal supervision maximum
down or when raising his supervision
head off the bed.

18. Palpation. Performed the Performed the Performed the Failed to perform
Penis: Palpate the shaft procedures with ease procedures with procedures with the procedure
for lesions, nodules, or minimal supervision maximum
masses; if present, note supervision
tenderness, contour, size,
and degree of in duration.

19. Scrotum. Palpate each Performed the Performed the Performed the Failed to perform
testis and epididymis, procedures with ease procedures with procedures with the procedure
assessing shape, and minimal supervision maximum
consistency. Note any supervision
masses or unusual
tenderness. Look for any
nodules or tenderness of
the spermatic, cord and
vas deferens.

Performed the Performed the Performed the Failed to perform

20. Inguinal and femoral
procedures with ease procedures with procedures with the procedure
areas. Assess for hernias.
minimal supervision maximum
supervision
RECTUM Performed the Performed the Performed the Failed to perform
21. Inspection. Examine procedures with ease procedures with procedures with the procedure
the anus and the perianal minimal supervision maximum
and sacral regions, with supervision
the client lying in the left
Sims position and
properly draped. If
necessary, use an
alternative position for
the examination, Male
clients may stand and
bend over the table;
female clients may
assume the lithotomy
position.
22. Spread the buttocks, Performed the Performed the Performed the Failed to perform
and note any procedures with ease procedures with procedures with the procedure
inflammation, nodules, minimal supervision maximum
scars, lesions, ulcerations, supervision
rashes, bleeding, fissures,
or hemorrhoids

23. Check for bulges Performed the Performed the Performed the Failed to perform
when the client bears procedures with ease procedures with procedures with the procedure
down. minimal supervision maximum
supervision
24. Palpation. Sphincter: Performed the Performed the Performed the Failed to perform
Ask the client to bear procedures with ease procedures with procedures with the procedure
down. Slowly insert your minimal supervision maximum
lubricated index finger of supervision
the gloved hand through
the anal sphincter. Assess
sphincter tone.
25. Rectum and rectal Performed the Performed the Performed the Failed to perform
walls. Gently rotate your procedures with ease procedures with procedures with the procedure
index finger to palpate minimal supervision maximum
the rectum and the rectal supervision
walls anteriorly and
posteriorly. Note any
nodules, masses or
tenderness, Palpate for
fecal impaction.

26. Prostate. In the male Performed the Performed the Performed the Failed to perform
client, anteriorly palpate procedures with ease procedures with procedures with the procedure
the two lateral lobes of minimal supervision maximum
the prostate gland for supervision
irregularities, nodules,
edema, or tenderness.

27. Fecal material. Performed the Performed the Performed the Failed to perform
Withdraw your finger procedures with ease procedures with procedures with the procedure
gently. Test any fecal minimal supervision maximum
material on the glove for supervision
occult blood.

Performed the Performed the Performed the Failed to perform

28. Remove gloves. procedures with ease procedures with procedures with the procedure
minimal supervision maximum
supervision
Properly and skillfully Placed the client Placed client Failed to
29. Position client positioned the client comfortably and in comfortably and in positioned client
comfortably after the comfortably any preferable any preferable properly and
assessment. position with less position with comfortably
supervision maximum
supervision
30. Inform client findings Performed the Performed the Performed the Failed to perform
as necessary. procedures with ease procedures with procedures with the procedure
minimal supervision maximum
 supervision
31. Wash hands and Washed hands and Washed hands and Washed hands but Washed hands
document findings and documented the some of the details most of the details but
report significant information about of procedure were of the procedure documentation
deviation from normal to the procedure not documented were not was not done
the physician properly and documented
completely

OVERALL SCORE: ________________

Target raw score is 70 out of 93. If raw score is less than 70, repeat the return demonstration.

_____________________________________

FACULTY SIGNATURE OVER PRINTED NAME

 OUR LADY OF FATIMA UNIVERSITY
COLLEGE OF NURSING - PAMPANGA

PROGRAM Bachelor of Science in Nursing Student Name

Year and Section
COURSE HEALTH ASSESSMENT Instructor
Date

PROCEDURE : Taking the Blood Pressure

EXPECTED OUTCOME : The student should be able to perform taking blood pressure
ASESSMENT TASK : Return demonstration

Exceptional Good Average Poor

Assessment Dimension SCORE
(3) (2) (1) (0)
1. Assess factors that Assessed factors Assessed two (2) Assessed one (1) Failed to assess
affect blood pressure that affect blood factors affecting factor affecting blood the factors that
pressure blood pressure pressure affect blood
pressure
2. Wash hands before Observed Hand washing was Hand washing was Hand washing
starting the procedure principles of done with minimal done with maximal was not done
medical hand error error
washing
3. Determine client’s Performed the Performed the Performed the Failed to
baseline blood pressure procedures with procedures with procedures with perform the
ease minimal maximum supervision procedure
supervision
4. Determine which Performed the Performed the Performed the Failed to
procedures with procedures with procedures with perform the
extremity is most
ease minimal maximum supervision procedure
appropriate for reading
supervision
5. Prepare materials. Gathered materials Gathered materials Gathered materials Failed to gather
Select a cuff size that needed with little time with more time all the materials
completely encircles preparation preparation needed
client’s upper arm
without overlapping ends

6. Identify the patient and Greeted and Performed the two Performed the one (1) Failed to
explain the procedure identified client by (2) ways of ways of identifying the identify the
asking his/her identifying the the the client client
name and checking client
his or her ID band
politely
7. Explain the procedure Explained Explained the Explained the Failed to explain
procedure and its procedure but lack procedure but in an procedure and
purpose to the some details. unclear manner. its purpose.
client clearly and
completely with
client’s consent
8. Place the client in an Properly and Placed the client Placed client Failed to
appropriate position skillfully positioned comfortably and in comfortably and in any positioned
the client any preferable preferable position client properly
comfortably position with less with maximum and comfortably
supervision supervision
9. Move client’s clothing Performed the Performed the Performed the Failed to
away from upper aspect procedures with procedures with procedures with perform the
of the arm ease minimal maximum supervision procedure
supervision
10. Position client’s arm Performed the Performed the Performed the Failed to
at heart level, extending procedures with procedures with procedures with perform the
elbow with palm turned ease minimal maximum supervision procedure
supervision
upward. Have client relax
arm and not overly
tighten elbow.

11. Wrap deflated cuff Performed the Performed the Performed the Failed to
evenly around the upper procedures with procedures with procedures with perform the
arm. For an adult, place ease minimal maximum supervision procedure
lower border of the cuff supervision
approximately 2.5cm
(1inch) above the
antecubital space

12. Apply cuff snugly Performed the Performed the Performed the Failed to
smoothly over upper arm procedures with procedures with procedures with perform the
ease minimal maximum supervision procedure
supervision
13. insert earpieces of Performed the Performed the Performed the Failed to
stethoscope into ears procedures with procedures with procedures with perform the
with a forward tilt ease minimal maximum supervision procedure
supervision
14. Relocate brachial Performed the Performed the Performed the Failed to
pulse and place the bell procedures with procedures with procedures with perform the
or diapraghm directly ease minimal maximum supervision procedure
supervision
over brachial pulse. Hold
the diaphragm with the
thumb and index finger

15. Close the valve of the Performed the Performed the Performed the Failed to
pump by turning the procedures with procedures with procedures with perform the
knob clockwise ease minimal maximum supervision procedure
supervision
16. Inflate cuff to Performed the Performed the Performed the Failed to
30mmHg above the procedures with procedures with procedures with perform the
normal systolic reading of ease minimal maximum supervision procedure
supervision
the client

17. Release the valve of Performed the Performed the Performed the Failed to
the cuff carefully so that procedures with procedures with procedures with perform the
the pressure decreases at ease minimal maximum supervision procedure
supervision
the rate of 2-3mmHg per
second. As the pressure
falls, identify the
manometer reading by
listening for the
korotkoff’s sounds

18. Mark the first audible Performed the Performed the Performed the Failed to
sound as the systolic procedures with procedures with procedures with perform the
pressure reading and the ease minimal maximum supervision procedure
supervision
last audible sound as the
diastolic pressure reading

19. After final sound has Performed the Performed the Performed the Failed to
disappeared, deflate cuff procedures with procedures with procedures with perform the
rapidly and completely ease minimal maximum supervision procedure
supervision
20. Remove cuff or wait Performed the Performed the Performed the Failed to
for 2 minutes before procedures with procedures with procedures with perform the
taking a second reading ease minimal maximum supervision procedure
supervision
21. Inform the client of Performed the Performed the Performed the Failed to
reading procedures with procedures with procedures with perform the
ease minimal maximum supervision procedure
supervision
22. Position client Properly and Placed the client Placed client Failed to
comfortably. skillfully positioned comfortably and in comfortably and in any positioned
the client any preferable preferable position client properly
comfortably position with less with maximum and comfortably
supervision supervision
23. Put all equipment in Performed the Performed the Performed the Failed to
proper place. procedures with procedures with procedures with perform the
ease minimal maximum supervision procedure
supervision
24. Wash hands and Washed hands and Washed hands and Washed hands but Washed hands
document pertinent data documented the some of the details most of the details of but
information about of procedure were the procedure were documentation
the procedure not documented not documented was not done
 properly and
completely

OVERALL SCORE: ________________

Target raw score is 54 out of 72. If raw score is less than 54, repeat the return demonstration.

_____________________________________
FACULTY SIGNATURE OVER PRINTED NAME
 OUR LADY OF FATIMA UNIVERSITY
COLLEGE OF NURSING - PAMPANGA

PROGRAM Bachelor of Science in Nursing Student Name

Year and Section
COURSE HEALTH ASSESSMENT Instructor
Date

PROCEDURE : Assessing the Appearance and Mental Status

EXPECTED OUTCOME : The student should be able to perform assessing appearance and mental
status
ASESSMENT TASK : Return demonstration

Exceptional Good Average Poor

Assessment Dimension SCORE
(3) (2) (1) (0)
Greeted and Performed the two Performed the one Failed to identify
1. Greet and identify the identified client by (2) ways of (1) ways of the client
asking his/her name identifying the the identifying the the
client
and checking his or client client
her ID band politely
Explained procedure Explained the Explained the Failed to explain
and its purpose to procedure but lack procedure but in procedure and its
2. Explain the procedure the client clearly and some details. an unclear purpose.
completely with manner.
client’s consent
Observed principles Hand washing was Hand washing was Hand washing
3. Wash hands before
of medical hand done with minimal done with maximal was not done
starting the procedure
washing error error
4. Observe body built, Performed the Performed the Performed the Failed to perform
height and weight in procedures with ease procedures with procedures with the procedure
relations to the client’s minimal supervision maximum
supervision
age, lifestyle and health
5. Observe the clientl’s Performed the Performed the Performed the Failed to perform
procedures with ease procedures with procedures with the procedure
posture and gait, standing
minimal supervision maximum
sitting and walking
supervision
6. Observe the client’s Performed the Performed the Performed the Failed to perform
overall hygiene and procedures with ease procedures with procedures with the procedure
grooming. Relate this to minimal supervision maximum
supervision
the persons activity prior
to the assessment
7. Note body and breath Performed the Performed the Performed the Failed to perform
odor in relation to the procedures with ease procedures with procedures with the procedure
activity level minimal supervision maximum
supervision
8. Observe for signs of Performed the Performed the Performed the Failed to perform
distress in posture and procedures with ease procedures with procedures with the procedure
facial expression minimal supervision maximum
supervision
9. Note obvious signs of Performed the Performed the Performed the Failed to perform
health or illness procedures with ease procedures with procedures with the procedure
minimal supervision maximum
supervision
10. Assess the client’s Performed the Performed the Performed the Failed to perform
attitude procedures with ease procedures with procedures with the procedure
minimal supervision maximum
supervision
11. Note the client’s Performed the Performed the Performed the Failed to perform
affect and mood. Assess procedures with ease procedures with procedures with the procedure
the client minimal supervision maximum
supervision
appropriateness of the
client’s responses
12. Listen for quality of Performed the Performed the Performed the Failed to perform
speech (amount and procedures with ease procedures with procedures with the procedure
pace), quality (loudness minimal supervision maximum
and clarity), and supervision
organizaion (coherence of
thought and vagueness)
13. Listen for relevance Performed the Performed the Performed the Failed to perform
and organization procedures with ease procedures with procedures with the procedure
minimal supervision maximum
supervision
14. Document the Documented the Some of the details Most of the details Documentation
findings information about of procedure were of the procedure was not done
the procedure not documented were not
properly and documented
completely

OVERALL SCORE: ________________

Target raw score is 32 out of 42. If raw score is less than 32, repeat the return demonstration.

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FACULTY SIGNATURE OVER PRINTED NAME