COLLEGE OF ALLIED HEALTH SCIENCES

NURSING DEPARTMENT
nd
2 Semester, A.Y. 2022 – 2023

HEALTH ASSESSMENT (RLE) CHECKLIST

NURSING SKILLS CHECKLIST PAGE

Health History: 2
● Interview using Assessment Tool for Nursing Health History
Assessment of Vital Signs:
● Temperature 5
● Pulse Rate 7
● Respiratory Rate 8
● Blood Pressure 9
● Pain 11
Assessment of the Appearance and Mental Status 12
Assessment of the Skin 13
Assessment of the Hair 14
Assessment of the Nails 15
Assessment of the Head, Face, and Skull 16
Assessment of the Eyes and its Structures 17
Assessment of the Ears and Hearing 19
Assessment of the Nose and Sinuses 21
Assessment of the Mouth and Oropharynx 22
Assessment of the Neck 24
Assessment of the Thorax and Lungs 25
Assessment of the Breast and Axillae 27
Assessment of the Heart and Central Vessels 29
Assessment of the Peripheral Vascular System 30
Assessment of the Abdomen 31
Assessment of the Musculoskeletal System 32
Assessment of the Neurologic System 33
Assessment of the Male Genitals and Inguinal Area 35
Assessment of the Female Genitals and Inguinal Area 36
Assessment of the Rectum and Anus 37

REFERENCES:

▪ Quiambao-Udan, J. (2009). Health assessment and physical examination (1st ed). Malabon: Giuani Prints House
▪ Estes, M. E. (2005). Health assessment and physical examination (3rd ed). Boston: Cengage Learning
▪ Schilling, J., et al. (2008). Assessment made incredibly easy! (4th ed). Philadelphia: Lippincott Williams & Wilkins
 COLLEGE OF ALLIED HEALTH SCIENCES
NURSING DEPARTMENT
nd
2 Semester, A.Y. 2022 – 2023

HEALTH ASSESSMENT (RLE) CHECKLIST

Nursing Skill: HEALTH HISTORY TAKING

Name:__________________________________ Date: __________

Able to
Able to Unable to
Skill Perform w/
Perform Perform
Assistance
3 2 1
Interview
1. Stated definition of ‘interview’
● The interview is a purposeful conversation between
the nurse and the patient.
2. Stated purpose of the interview
● Gather organized, complete, and accurate data about
the patient’s health state.
● Establish rapport and trust
● Teach the client about the health state so that he/she
can participate in identifying problems and planning
for health care
Preparatory Phase
1. Stated definition of Preparatory Phase
● The Preparatory Phase or Pre-interaction Phase
occurs before the nurse meets the client
2. Reviewed as much information as possible about the patient
● To ensure that the interview will be as productive as
possible
Introduction Phase
1. Stated the definition of Introduction Phase
● It begins when the nurse and the patient meet
2. Introduced self by name and position and explain the purpose
and content of the interview
● To establish rapport, clarifying roles, and alleviate
anxiety
3. Let the client know how long the nurse – patient relationship is
expected to last
4. Inform the patient how the information collected will be used
and that confidentiality will be maintained
Maintenance Phase
1. Stated the definition of Maintenance Phase
● The nurse and patient work toward achieving the
specific task or goal agreed on the introductory phase.
 Able to
Able to Unable to
Biographic Data Perform w/
Perform Assistance Perform
3 2 1
Asked for the client’s:
1. Client’s Name
2. Address and phone Number
3. Age and Birth Date
4. Birthplace
5. Sex
6. Religion
7. Marital Status
8. Ethnicity
9. Primary and Secondary Language
10. Educational Level
 11. Occupation
12. Significant Others or Support Persons
Reason for Seeking Care
1. Asked for the client’s chief complaint
2. Differentiated ‘Sign’ from ‘Symptom’
● Sign is an objective abnormality
● Symptom is a subjective sensation
Present Health or History of Present Illness
1. Asked for the client’s chronological record of the reason for
seeking care, from the time the symptom first started until now
Asked for the characteristics of the symptoms:
2. Location
● “Is the pain located at this site?”
3. Quality or Character
● Specific descriptive terms such as ‘burning, sharp,
dull, aching, gnawing throbbing, shooting’
4. Quantity or Severity
● “Profuse menstrual flow soaking five pads per hour”
5. Timing
● When did the symptoms first appear? How long did
the symptoms last?
6. Setting
● Where was the person or what was the person doing
when the symptom started?
7. Aggravating or Relieving Factors
● What makes the pain worse?
Past Health History
Asked for the client’s:
1. Childhood illness
2. Accidents or injuries
3. Serious or Chronic Illnesses
4. Hospitalization
5. Operations
6. Obstetric History
7. Immunizations
8. Last Examination Date
9. Allergies
Current Medications
1. Noted all prescription and over-the-counter medications and
herbal remedies
2. Noted name, dose and schedule and ask what the medication
is for
Family History
1. Age of Parents
2. Asked about age and cause of death of blood relatives
3. Ask Family History of:
● heart disease
● high blood pressure
● stroke
● diabetes
● blood disorders
● cancer
● anemia
● arthritis
 ● allergies
● obesity
● alcoholism
● mental illness
● seizure disorders
● kidney disease
● tuberculosis.

Termination
1. Stated definition of ‘Termination Phase’
● Termination phase encourages the client to identify the
progress that he/she had made and explores the
necessity of any referral that maybe beneficial to the
patient.
2. Therapeutically ended the nurse-client relationship
TOTAL

COMMENTS: GRADE:

Student’s Signature Clinical Instructor’s Signature

 Nursing Skill: VITAL SIGN ASSESSMENT - TEMPERATURE

Name:
Date:

Able to
Able to Unable to
Skill Assessment Perform w/
Perform Perform
Assistance
3 1
2
1. Assess body temperature for changes due to exposure to pyrogens
or to extreme hot or cold external environments.
2. Assess the client for the most appropriate site to check his
temperature.
3. Confirm that the client has not consumed hot or cold foods nor
smoked just before the measurement of an oral temperature.
4. Assess for mouth breathing and tachypnea.
5. Assess for oral herpetic lesions.
Planning/Expected Outcomes
1. An accurate temperature reading will be obtained.
2. The client will verbalize understanding of the reason for the
procedure.
Implementation
Preparation
1. Review medical record for factors that influence vital signs.
2. Explain to the client that vital signs will be assessed.
3. Assess client’s toileting needs and proceed as appropriate.
4. Gather equipment as indicated.
5. Provide for privacy.
6. Wash hands and apply gloves.
7. Position the client in a sitting or lying position with the head of the bed
elevated 45 to 60 degrees, unless taking a rectal or tympanic
temperature.
8. Wash hands when finished performing skill.
Oral Temperature: Electronic Thermometer
9. Repeat steps 1 through 8.
10. Place disposable protective sheath over probe.
11. Grasp top of the probe’s stem.
12. Place tip of thermometer under the client’s tongue and along the gum
line.
13. Instruct client to keep mouth closed around thermometer.
14. Thermometer will signal (beep) when a constant temperature
registers.
15. Read measurement on digital display. Push ejection button to discard
disposable sheath and return probe to storage well.
16. Inform client of temperature reading.
17. Remove gloves and wash hands.
18. Record reading and indicate site as oral or OT (oral temperature).
19. Return electronic thermometer unit to charging base.
20. Wash hands.
Rectal Temperature
21. Repeat steps 1 through 8.
22. Place client in the Sims’ position with upper knee flexed. Expose only
anal area.
23. Place tissues in easy reach. Apply gloves.
24. Prepare the thermometer.
25. Lubricate tip of rectal thermometer or probe with water-soluble
lubricant.
26. Grasp thermometer with one hand and spate buttocks to expose
anus with the other.
27. Instruct client to take a deep breath. Insert thermometer or probe
gently into anus.
28. Hold in place for 2 minutes.
29. Wipe secretions off glass thermometer with a tissue and dispose of tissue
in waste receptacle. Dispose of electronic thermometer cover
in waste receptacle.
30. Read measurement and inform client of temperature reading.
31. Wipe anal area with tissue to remove lubricant or feces. Cover client
32. Cleanse thermometer.
33. Remove and dispose of gloves in appropriate receptacle. Wash
hands.
34. Record reading and indicate site as “RT” (rectal temperature).
Axillary Temperature
35. Repeat steps 1 through 8.
36. Remove client’s arm and shoulder from sleeve of gown. Avoid
exposing chest.
37. Make sure axillary skin is dry; if necessary, pat dry.
38. Prepare thermometer.
39. Place thermometer or probe into center of axilla. Fold client’s arm
across chest.
40. Leave glass thermometer in place 6 to 8 minutes. Leave an electronic
thermometer in place until signal is heard
41. Remove and read thermometer.
42. Inform client of temperature reading.
43. Shake glass thermometer down, cleanse, rinse, and return to
storage. Dispose of probe cover for electronic thermometer in waste
receptacle.
44. Assist client with replacing gown.
45. Record reading and indicate site as “AT” (axillary temperature).
46. Wash hands.
Tympanic Temperature: Infrared Thermometer
47. Repeat steps 1 through 8.
48. Position client in Sims’ position or seated position.
49. Attach probe cover to tympanic thermometer unit.
50. Turn client’s head to one side. Gently insert probe with firm pressure
into ear canal.
51. Remove probe after the reading is displayed on digital unit.
52. Dispose of probe cover appropriately.
53. Return tympanic thermometer to storage unit.
54. Record reading and indicate site as “ET” (ear temperature).
55. Wash hands.
TOTAL

COMMENTS: GRADE:

Student’s Signature Clinical Instructor’s Signature

Nursing Skill: VITAL SIGN ASSESSMENT – PULSE RATE

Name:
Date:

Able to
Able to Unable to
Skill Assessment Perform w/
Perform Assistance Perform
3 2 1
1. Assess client for need to monitor pulse.
2. Assess for signs of cardiovascular alterations.
3. Assess for factors that may affect the character of the pulse.
4. Assess for appropriate site for obtaining pulse.
5. Assess baseline heart rate and rhythm in the client’s chart.
Planning/Expected Outcomes
1. Pulse parameters will be within normal range.
2. The client will be comfortable with the procedure.
Implementation
Taking a Radial (Wrist) Pulse
1. Wash hands.
2. Inform client of the site(s) at which you will measure pulse.
3. Flex client’s elbow and place lower part of arm across chest.
4. Support client’s wrist by grasping outer aspect with thumb.
5. Place your index and middle finger over the radial artery and palpate
pulse.
6. Identify pulse rhythm.
7. Determine pulse volume.
8. Count pulse rate by using second hand on a watch.
Taking an Apical Pulse
9. Wash hands.
10. Cleanse stethoscope with an alcohol swab.
11. Put stethoscope around your neck.
12. Raise client’s gown to expose sternum and left side of chest.
13. Locate apex of heart.
14. Instruct client to remain silent so you can listen to his heart.
15. Put earpieces in your ears and warm stethoscope diaphragm in your
hand.
16. Place diaphragm over the PMI and auscultate for sounds.
17. Note regularity of rhythm.
18. Start to count while looking at second hand of watch. Count apical
heart rate in all clients for 1 full minute.
19. Share your findings with client.
20. Record site, rate, rhythm, and number of irregular beats.
21. Wash hands.
TOTAL

COMMENTS: GRADE:

Student’s Signature Clinical Instructor’s Signature

 Nursing Skill: VITAL SIGN ASSESSMENT – RESPIRATORY RATE

Name:
Date:

Able to
Able to Unable to
Skill Assessment Perform w/
Perform Perform
Assistance
3 1
2
1. Assess the client’s chest wall movement.

2. Assess the rate of respirations.

3. Assess the depth of the client’s breaths.

4. Assess for risk factors.

5. Assess for factors that normally influence respirations.

Planning/Expected Outcomes
1. An accurate evaluation of the respiratory effort will be obtained.
2. The respiratory rate and character will be normal.
Implementation
1. Wash hands.
2. Ensure chest movement is visible.

3. Observe one complete respiratory cycle.

4. Start counting with first inspiration while looking at the second hand
of watch.
5. Observe character of respirations.

6. Replace client’s gown if needed.

7. Record rate and character of respirations.

8. Wash hands.

TOTAL

COMMENTS: GRADE:

Student’s Signature Clinical Instructor’s Signature

 Nursing Skill: VITAL SIGN ASSESSMENT – BLOOD PRESSURE

Name:
Date:

Able to
Able to Unable to
Skill Assessment Perform w/
Perform Assistance Perform
3 2 1
1. Assess the condition of the potential blood pressure (BP) site.

2. Assess the artery for any compromise.

3. Assess the distal pulse.

4. Assess the circumference of the extremity.

5. Assess for factors that affect blood pressure.

6. Determine client’s baseline blood pressure.

Planning/Expected Outcomes:
1. An accurate estimate of the arterial pressure at diastole and systole
will be obtained.

2. BP is within normal range for the client.

3. Client will be able to explain why the BP is taken and what it means.
Implementation:
Auscultation Method Using Brachial Artery
1. Wash hands.
2. Determine which extremity is most appropriate for reading.
3. Select a cuff size that completely encircles client’s upper arm without
overlapping bladder ends.
4. Move client’s clothing away from upper aspect of arm.
5. Position client’s arm at heart level, extending elbow with palm turned
upward. Have client relax arm and not overly tighten elbow.
6. Make sure bladder cuff is fully deflated and pump valve moves freely.

7. Locate brachial artery in the antecubital space.

8. Apply cuff snugly and smoothly over upper arm.

9. If using a portable, mercury-filled manometer, position vertically at
eye level.
10. Palpate brachial artery, close valve, and compress bulb to inflate cuff.
Slowly release valve, noting reading when pulse is felt again.
11. Insert earpieces of stethoscope into ears with a forward tilt.
12. Relocate brachial pulse and place bell or diaphragm directly over
pulse.
13. Turn valve to close. Inflate cuff to 30 mm Hg above previously noted
diminished pulse point.
14. Slowly open valve so mercury falls 2 to 3 mm Hg over second. Note
manometer readings when sounds appear and disappear.
15. After the final sound has disappeared, deflate cuff rapidly and
completely.
16. Remove cuff or wait 2 minutes before taking a second reading.

17. Inform client of reading.

18. Record reading.
19. If appropriate, lower bed, raise side rails, and place call light in easy
reach.
20. Put all equipment in proper place.

21. Wash hands.

Palpation Method Using Brachial or Radial Artery:
22. Palpate brachial or radial artery with fingertips. Inflate cuff 30 mm Hg
above point at which pulse disappears.
23. Deflate cuff slowly as you note on the manometer when the pulse is
again palpable.
24. Deflate cuff rapidly and completely.

25. Remove cuff or wait 2 minutes before taking a second reading.

26. Inform client of reading.

27. Record reading.

28. Wash hands.

TOTAL

COMMENTS: GRADE:

Student’s Signature Clinical Instructor’s Signature

 Nursing Skill: VITAL SIGN ASSESSMENT – PAIN

Name:
Date:

Able to
Able to Unable to
Skill Assessment Perform w/
Perform Assistance Perform
3 2 1
1. Stated the definition of ‘Pain’
● A sensation of physical or mental hurt or suffering that causes
distress or agony to the one experiencing it.

2. PQRST pain assessment

● Provocative or Palliative
▪ What brings it on? What were you doing when you first
noticed it? what makes it better/worse?
● Quality or Quantity
▪ How does it feel?
● Region or Radiation
▪ Where is it?
● Severity
▪ How bad is it (on a scale of 1 to 10?), is it getting better or
worse?
● Timing
▪ Onset – exactly when did it first occur?
▪ Duration – How long did it last?
▪ Frequency – How often does it occur?

3. Performed aftercare.

4. Documented all findings.

TOTAL

COMMENTS: GRADE:

Student’s Signature Clinical Instructor’s Signature

 Nursing Skill: ASSESSING THE APPEARANCE AND MENTAL STATUS

Name:
Date:

Able to
Able to Unable to
Skill Assessment Perform w/
Perform Assistance Perform
3 2 1
1. Greet and identify the client. Explain the procedure

2. Wash hands and observe appropriate infection control procedures

3. Provide the client privacy

4. Observe body build, height and weight in relation to the client’s age,
lifestyle and health
5. Observe the client’s posture and gait, standing, sitting and walking
6. Observe the client’s overall hygiene and grooming. Relate these to
the person’s activity prior to the assessment
7. Note body and breath odor in relation to activity level

8. Observe for signs of distress in posture or facial expression

9. Note obvious signs of health or illness

10. Assess the client’s attitude

11. Note the clients affect/mood. Assess the appropriateness of the
client’s responses
12. Listen for quantity of speech (amount and pace) quality (loudness, clarity,
inflection) and organization (coherence of thought and
vagueness).
13. Listen for relevance and organization of thoughts

14. Document findings

TOTAL

COMMENTS: GRADE:

Student’s Signature Clinical Instructor’s Signature

 Nursing Skill: ASSESSING THE SKIN

Name:
Date:

Able to
Able to Unable to
Skill Assessment Perform w/
Perform Assistance Perform
3 2 1

1. Inquire if the client has any history of skin allergies and skin problems

2. Inspect for skin color and uniformity of skin color

3. Assess edema if present. Note location, color, temperature, shape and

the degree to which the skin remains indented or pitted when
pressed by a finger.
4. Inspect, palpate and describe skin lesions. Don gloves if lesions are
open or draining. Palpate lesions to determine shape and texture.
Describe lesions according to location, color, configuration, size,
shape, type and structure.

5. Observe and palpate skin moisture

6. Palpate skin temperature. Compare the two feet and the two hands
using the back of the fingers
7. Note skin turgor (fullness or elasticity) by lifting and pinching the skin on
an extremity

8. Position client comfortably after the assessment

9. Inform client findings as necessary

10. Wash hands.

11. Document findings and report significant deviation from normal to the
physician

TOTAL

COMMENTS: GRADE:

Student’s Signature Clinical Instructor’s Signature

 Nursing Skill: ASSESSING THE HAIR

Name:
Date:

Able to
Able to Unable to
Skill Assessment Perform w/
Perform Assistance Perform
3 2 1
1. Assemble equipment:
● Clean gloves.
2. Introduce self & verify the client’s identity. Explain to the client what
you are going to do, why it is necessary, and how the client can
cooperate.

3. Provide for client privacy.

4. Inquire if client has any history of the following:

● Recent use of hair dyes, rinses, or curling or straightening
preparations.
● Recent chemotherapy.
● Presence of disease.

5. Inspect the evenness of growth over the scalp.

6. Inspect hair thickness or thinness.

7. Inspect hair texture and oiliness.

8. Note the presence of infections or infestations by parting the hair in

several areas and checking behind the ears and along the hairline at
the neck.

9. Inspect the amount of body hair.

10. Document findings in the client record.

TOTAL

COMMENTS: GRADE:
Nursing Skill: ASSESSING THE NAILS

Name:
Date:

Able to
Able to Unable to
Skill Assessment Perform w/
Perform Assistance Perform
3 2 1
1. Introduce self & verify the client’s identity. Explain to the client what
you are going to do, why it is necessary, and how the client can
cooperate.

2. Observe appropriate infection control procedures.

3. Provide for client privacy.

4. Inquire if client has any history of the following:

● Diabetes mellitus
● Peripheral circulatory disease
● Previous injury
● Severe illness

5. Inspect fingernail plate shape to determine its curvature and angle.

6. Inspect fingernail and toenail texture.

7. Inspect fingernail and toenail bed color.

8. Inspect tissues surrounding nails.

9. Perform blanch test of capillary refill.

● Press two or more nails between your thumb & index finger; look
for blanching and return of pink color to nail bed.

10. Document findings in the client record.

TOTAL

COMMENTS: GRADE:
Nursing Skill: ASSESSING THE HEAD, FACE, AND SKULL

Name:
Date:

Able to
Able to Unable to
Skill Assessment Perform w/
Perform Assistance Perform
3 2 1
1. Introduce self & verify the client’s identity. Explain to the client what
you are going to do, why it is necessary, and how the client can
cooperate.

2. Observe appropriate infection control procedures.

3. Provide for client privacy.

4. Palpation:
● Skull: Inspect for size, shape and symmetry
● Scalp: inspect for dandruff, lesions, and masses
● Face: Note symmetry of facial movements. Assess function of the
facial nerve. Ask the client to smile, frown, elevate and lower
eyebrows, close eyes tightly, puff the cheeks and show the teeth
5. Palpation:
● Skull: Palpate for nodules or masses and depressions
● Face: palpate the temporomandibular joint for pain and
tenderness

6. Position client comfortably after the assessment.

7. Inform the client findings as necessary.

8. Wash hands.

9. Document findings and report significant deviation from the normal to the
physician.

TOTAL

COMMENTS: GRADE:

Student’s Signature Clinical Instructor’s Signature

 Nursing Skill: ASSESSING THE EYES AND ITS STRUCTURES

Name:
Date:

Able to
Able to Unable to
Skill Assessment Perform w/
Perform Assistance Perform
3 2 1
1. Assemble equipment and supplies:
● Cotton-tipped applicator
● Examination gloves
● Gauze
● Millimeter ruler
● Penlight
Procedure
1. Introduce self & verify the client’s identity. Explain to the client what
you are going to do, why it is necessary, and how the client can
cooperate.
2. Perform hand hygiene and observe other appropriate infection control
procedures.
3. Provide for client privacy.
4. Inquire if the client has any history of the following:
● Family history of diabetes, hypertension, or blood dyscrasia
● Eye disease, injury, or surgery
● Last visit to an ophthalmologist
● Current use of eye medications
● Use of contact lenses or eyeglasses
● Hygienic practices for corrective lenses
● Current symptoms of eye problems
Assessment: External Eye Structures
5. Inspect the eyebrows for hair distribution and alignment, and for skin
quality & movement.
6. Inspect the eyelashes for evenness of distribution and direction of the
curl.
7. Inspect the eyelids for surface characteristics, position in relation to the
cornea, ability to blink, and frequency of blinking. Inspect the
lower eyelids while the client’s eyes are closed.
8. Inspect the bulbar conjunctiva for color, texture, and the presence of
lesions.
9. Inspect the palpebral conjunctiva everting the lids.
10. Evert the upper lids if a problem is suspected.
● Ask the client to look down while keeping the eyelids slightly
open.
● Gently grasp the client’s eyelashes with thumb and forefinger.
Pull lashes gently downwards.
● Place a cotton-tipped applicator stick about 1cm above the lid
margin, and push it gently downwards while holding the
eyelashes.
● Hold the margin of the everted lid or eyelashes against the ride of
the upper bony orbit with the applicator stick or your thumb.
● Inspect the conjunctiva for color, texture, lesions, and foreign
bodies.
11. Inspect and palpate the lacrimal gland.
● Using the tip of your index finger, palpate the lacrimal gland.
● Observe for edema between the lower lid and the nose.
12. Inspect and palpate the lacrimal sac and nasolacrimal duct.
● Observe for evidence of increased tearing.
● Using the tip of your index finger, palpate inside the lower orbital
rim near the inner canthus.
13. Inspect the cornea for clarity and texture. Ask the client to look straight
ahead. Hold a penlight at an oblique angle to the eye, and
move the light slowly across the corneal surface.
14. Perform the corneal sensitivity (reflex) test to determine the function
th
of the 5 cranial nerve. Ask the client to keep both eyes open and
look straight ahead. Approach from behind and beside the client, and
lightly touch the cornea with a corner of the gauze.
15. Inspect the anterior chamber for transparency and depth. Use the
same oblique lighting used when testing the cornea.
16. Inspect the pupils for color, shape, and symmetry of the size.
17. Assess each pupil’s direct and consensual reaction to light.
● Partially darken a room.
● Ask the client to look straight ahead.
● Using a penlight and approaching from the side, shine a light on
the pupil.
● Observe the response. The pupil should constrict (direct
response).
● Shine the light on the pupil again, and observe the response of the
other pupil. It should also constrict (consensual response).
18. Assess each pupil’s reaction to accommodation.
● Hold an object about 10cm from the client’s nose.
● Ask the client to look first at the top of the object and then at a
distant object behind the penlight. Alternate the gaze between the
near and far objects.
● Observe the pupil response. Pupils should constrict when looking at
the near object and dilate when looking at the far object.
● Next, move the penlight or pencil toward the client’s nose. The
pupils should converge. To record normal assessment of the
pupils, use the abbreviation PERRLA.
Extraocular Muscle Tests
19. Assess six ocular movements to determine eye alignment and
coordination.
● Stand directly in front of the client and hold the penlight at a
comfortable distance, such as 30 cm in front of the client’s eyes.
● Ask the client to hold head in a fixed position facing you and follow
the movements of the penlight with eyes only.
● Move the penlight in a slow, orderly manner through the six
cardinal fields of gaze.
● Stop the movement of the penlight periodically so that the
nystagmus can be detected.
20. Assess for location of light reflex by shining a penlight on the pupil in
corneal surface (Hirschberg Test).
21. Have the client fixate on a near or far object. Cover one eye and
observe for movement in the uncovered eye (Cover Test).
22. Document findings in the client record.
TOTAL

COMMENTS: GRADE:

Student’s Signature Clinical Instructor’s Signature

 Nursing Skill: ASSESSING THE EARS AND HEARING

Name:
Date:

Able to
Able to Unable to
Skill Assessment Perform w/
Perform Assistance Perform
3 2 1
1. Assemble equipment.
● Examination gloves
● Tuning fork
Procedure
1. Introduce self & verify the client’s identity. Explain to the client what
you are going to do, why it is necessary, and how the client can
cooperate.
2. Perform hand hygiene and observe other appropriate infection control
procedures.

3. Provide for client privacy.

4. Inquire if the client has any history of the following:

● Family history of hearing problems
● Presence of any ear problems or pain
● Medication history, especially if there are complaints of ringing in
ears
● Any hearing difficulty: its onset, factors contributing to it, and how it
interferes with activities of daily living
● Use of a corrective hearing device: when and from whom it was
obtained

5. Position the client comfortably – seated, if possible.

Assessment: Auricles
6. Inspect the auricles for color, symmetry of size, and position. To
inspect position, note the level at which the superior aspect of the
auricle attaches to the head with relation to the eye.
7. Palpate the auricles for texture, elasticity, and areas of tenderness.
● Gently pull the auricle upward, downward, and backward.
● Fold the pinna forward. It should be recoiled.
● Push in on the tragus.
● Apply pressure to the mastoid process.
Gross Hearing Acuity Test
8. Assess the client’s responses to normal voice tones. If the client has
difficulty hearing the normal voice, proceed with the following tests:

● Watch Tick Test – Have the client occlude one ear. Out of the
client’s sight, place a ticking watch 2-3 cm (1-2 inches) from the
unoccluded ear. Ask what the client can hear. Repeat with the
other ear.

● Tuning Fork Tests

o Weber Test – Hold the tuning fork at its base. Activate it by

tapping the fork gently against the back of your hand near
the knuckles or by stroking the fork between your thumb
and index finger. Place the base of the vibrating fork on top
of the client’s head and ask whether the client hears the
noise.
 o Rinne Test – Ask the client to block the hearing in one ear
intermittently by moving a fingertip in and out of the ear
canal. Hold the handle of activated tuning fork on mastoid
process of one ear until the client states that the vibration no
longer can be heard. Immediately hold still the vibrating fork
prongs in front of the client’s ear canal. If necessary, push
aside the client’s hair. Ask whether the client now
hear the sound.

9. Document findings in the client record.

TOTAL

COMMENTS: GRADE:

Student’s Signature Clinical Instructor’s Signature

 Nursing Skill: ASSESSING THE NOSE AND SINUSES

Name:
Date:

Able to
Able to Unable to
Skill Assessment Perform w/
Perform Assistance Perform
3 2 1
1. Assemble equipment.
● Nasal speculum
● Flashlight or penlight
Procedure
1. Introduce self & verify the client’s identity. Explain to the client what
you are going to do, why it is necessary, and how the client can
cooperate.
2. Perform hand hygiene and observe other appropriate infection control
procedures.
3. Provide for client privacy.
4. Inquire if the client has any history of the following:
● Allergies
● Difficulty breathing through the nose
● Sinus infections
● Injuries to nose or face
● Nosebleeds
● Any medications taken
● Any changes in sense of smell
5. Position the client comfortably – seated, if possible.
Assessment: Nose
6. Inspect the external nose for any deviations in shape, size, or color
and flaring, or discharge from the nares.
7. Lightly palpate the external nose to determine any areas of
tenderness, masses, or displacements of bone and cartilage.
8. Determine patency of both nasal cavities.
● Ask the client to close the mouth, exert pressure on one naris, and
breathe through the opposite naris. Repeat the procedure to assess
patency of the opposite naris.
9. Inspect the nasal cavities using a flashlight.
10. Observe the presence of redness, swelling, growths, and discharge.
11. Inspect the nasal septum between the nasal chambers.
Assessment: Facial Sinuses
12. Palpate the maxillary and frontal sinuses for tenderness.
13. Document findings in the client record.
TOTAL

COMMENTS: GRADE:

Student’s Signature Clinical Instructor’s Signature

 Nursing Skill: ASSESSING THE MOUTH AND OROPHARYNX

Name:
Date:

Able to
Able to Unable to
Skill Assessment Perform w/
Perform Assistance Perform
3 2 1
1. Assemble equipment.
● Clean gloves
● Tongue depressor
● 2x2 gauze pads
● Penlight

Procedure
1. Introduce self & verify the client’s identity. Explain to the client what
you are going to do, why it is necessary, and how the client can
cooperate.
2. Perform hand hygiene and observe other appropriate infection control
procedures.
3. Provide for client privacy.
4. Inquire if the client has any history of the following:
● Routine pattern of dental care
● Last visit to dentist
● Length of time ulcers or other lesions have been present
● Any denture discomfort
● Any medications the client is receiving

5. Position the client comfortably – seated, if possible.

Assessment: Lips and Buccal Mucosa

6. Inspect the outer lips for symmetry of contour, color, and texture.
● Ask the client to purse lips as if to whistle.
7. Inspect & palpate the inner lips and buccal mucosa for color,
moisture, texture, and the presence of lesions.
Assessment: Teeth and Gums
8. Inspect the teeth and gums while examining the inner lips and buccal
mucosa. Inspect the dentures.
Assessment: Tongue/Floor of the Mouth
9. Inspect the surface of the tongue for position, color, and texture.
● Ask client to protrude the tongue and move it from side to side.

10. Inspect the tongue movement.

11. Inspect the base of the tongue, the mouth floor, and the frenulum.
12. Palpate the tongue and floor of the mouth for any modules, lumps, or
excoriated areas.
● Use a piece of gauze to grasp the tip of the tongue and, with the
index finger of your other hand, palpate the back of the tongue, its
borders and its base.

Assessment: Salivary Glands

13. Inspect salivary duct openings for any swelling or redness.

Assessment: Palates and Uvula

14. Inspect the hard and soft palate for color, shape, texture, and the
presence of bony prominences.
 ● Ask the client to open mouth wide and tilt head backward. Then,
depress tongue with a tongue blade as necessary, and use a
penlight for appropriate visualization.
15. Inspect the uvula for position and mobility while examining the
palates.
● To observe the uvula, ask the client to say “ah” so that the soft
palate rises.
Assessment: Oropharynx and Tonsils
16. Inspect the oropharynx for color and texture.
● Inspect one side at a time to avoid eliciting the gag reflex. To
expose one side of the oropharynx, press a tongue blade against
the tongue on the same side about halfway back while the client tilts
head back and opens mouth wide. Use a penlight for
illumination, if needed.
17. Inspect the tonsils for color, discharge, and size.
18. Elicit the gag reflex by pressing the posterior tongue with a tongue
blade.
19. Document findings in the client record.

TOTAL

COMMENTS: GRADE:

Student’s Signature Clinical Instructor’s Signature

 Nursing Skill: ASSESSING THE NECK

Name:
Date:

Able to
Able to Unable to
Skill Assessment Perform w/
Perform Assistance Perform
3 2 1
1. Introduce self & verify the client’s identity. Explain to the client what
you are going to do, why it is necessary, and how the client can
cooperate.
2. Perform hand hygiene and observe other appropriate infection control
procedures.
3. Provide for client privacy.
4. Inquire if the client has any history of the following:
● Any problems with neck lumps
● Neck pain or stiffness
● When and how any lumps occurred
● Any diagnoses of thyroid problems
● Any treatments such as surgery or radiation
Assessment
5. Inspect the neck muscles for abnormal or masses.
● Ask the client to hold head erect.
6. Observe head movement. Ask the client to:
● Move chin to the chest.
● Move head back so that the chin points upward.
● Move head so that the ear is moved toward the shoulder on
each side.
● Turn head to the right and to the left.
7. Assess muscle strength:
● Ask the client to turn head to one side against the resistance of
your hand. Repeat with the other side. Shrug shoulders against
the resistance of your hands.
8. Palpate the entire neck for enlarged lymph nodes.
9. Palpate the trachea for lateral deviation.
● Place your fingertip or thumb on the trachea in the suprasternal
notch, then move your finger laterally to the left and the right in
spaces bordered by the clavicle, the anterior aspect of the
sternocleidomastoid muscle, and the trachea.
10. Inspect the thyroid gland.
● Stand in front of the client.
● Observe the lower half of the neck overlying the thyroid gland for
symmetry and visible masses.
● Ask the client to hyperextend head and swallow. If necessary,
offer a glass of water to make it easier for the client to swallow.
11. Palpate the thyroid gland for smoothness. Note any areas of
enlargement, masses, or nodules.
12. If enlargement of the gland is suspected:
● Auscultate over the thyroid area for a bruit.
● Use the bell-shaped diaphragm of the stethoscope.
13. Document findings in the client record.
TOTAL

COMMENTS: GRADE:

Student’s Signature Clinical Instructor’s Signature

 Nursing Skill: ASSESSING THE THORAX AND LUNGS

Name:
Date:

Able to
Able to Unable to
Skill Assessment Perform w/
Perform Assistance Perform
3 2 1
1. Assemble equipment.
● Stethoscope
● Skin marker or pencil
● Centimeter ruler

Procedure
1. Introduce self & verify the client’s identity. Explain to the client what
you are going to do, why it is necessary, and how the client can
cooperate.
2. Perform hand hygiene and observe other appropriate infection control
procedures.
3. Provide for client privacy.
4. Inquire if the client has any history of the following:
● Family history of illness, including cancer
● Allergies
● Tuberculosis
● Lifestyle habits such as smoking & occupational hazards
● Any medications being taken
● Current problems such as swellings, coughs, wheezing, pain

Assessment: Posterior Thorax

5. Inspect the shape & symmetry of thorax from posterior & lateral
views. Compare the anteroposterior diameter to the transverse
diameter.
6. Inspect the spinal alignment for deformities.
● Have the client stand. From a lateral position, observe the three
normal curvatures – cervical, thoracic, and lumbar.
● To assess for lateral deviation of spine, observe the standing
client from the rear. Have the client bend forward at the waist and
observe from behind.
7. Palpate the posterior thorax.
● For no respiratory complaints, rapidly assess the temperature &
integrity of all chest skin. Palpate all chest areas for bulges,
tenderness, or abnormal movements. Avoid deep palpation for
painful areas, especially if fractured rib is suspected.
8. Palpate the posterior chest for respiratory excursion.
● Place the palms of both hands over the lower thorax, with thumbs
adjacent to the spine & your fingers stretched laterally. Ask the client
to take deep breath while you observe the movement of
your hands and any lag in movement.
9. Palpate the chest for vocal (tactile) fremitus.
● Place the palmar surfaces of fingertips or ulnar aspect of hand or
closed fist on the posterior chest, starting near the apex of lungs.
● Ask the client to repeat such word as “blue moon”, or “one, two,
three.”
● Repeat the two steps, moving your hands sequentially to the
base of the lungs.
● Compare the fremitus on both lungs & between the apex and the
base of each lung.

10. Percuss the thorax.

11. Percuss for diaphragmatic excursion.
12. Auscultate the chest using the flat-disc diaphragm of stethoscope.
● Use the systematic zigzag procedure used in percussion.
● Ask the client to take slow, deep breaths through the mountain.
Listen at each point to the breath sounds during a complete
inspiration and expiration.
● Compare findings at each point with the corresponding point on
the opposite side of the chest.

Assessment: Anterior Thorax

13. Inspect the breathing patterns.

14. Inspect the costal angle and the angle at which the ribs enter the
spine.
15. Palpate the anterior chest.

16. Palpate the anterior chest for respiratory excursion.

17. Palpate tactile fremitus in the same manner as the posterior chest.

18. Percuss the anterior chest symmetrically.

19. Auscultate the trachea.

20. Auscultate the anterior chest.

21. Document findings in the client record.

TOTAL

COMMENTS: GRADE:

Student’s Signature Clinical Instructor’s Signature

 Nursing Skill: ASSESSING THE BREAST AND AXILLAE

Name:
Date:

Able to
Able to Unable to
Skill Assessment Perform w/
Perform Perform
Assistance
3 2 1

1. Assemble equipment.
● Centimeter ruler

Procedure
1. Introduce self & verify the client’s identity. Explain to the client what
you are going to do, why it is necessary, and how the client can
cooperate.
2. Perform hand hygiene and observe other appropriate infection control
procedures.

3. Provide for client privacy.

4. Inquire if the client has any history of the following:

● Breast masses, & what was done about them
● Any pain or tenderness in breasts & relation to the woman’s
menstrual cycle
● Any discharge from the nipple
● Medication history
● Estrogen replacement therapy
● Family history of breast cancer
● Alcohol consumption
● High-fat diet
● Obesity
● Use of contraceptive
● Menarche before age 12; menopause after age 30
● Breast self-examination

Assessment

5. Inspect the breasts for size, symmetry, and contour or shape while
the client is in sitting position.

6. Inspect the skin of the breast for localized discolorations or

hyperpigmentation, retraction, or dimpling, localized hypervascular
areas, swelling, or edema.
7. Emphasize any retraction by having the client:
● Raise arms above head
● Push the hands together, with elbows flexed
● Press hands down on hips

8. Inspect the areola area for size, shape, symmetry, color, surface
characteristics, and any masses or lesions.

9. Inspect the nipples for size, shape, position, color, discharge, and
lesions.
10. Palpate the axillary, sub-clavicular, and supraclavicular lymph nodes.
● The client is seated with her arms abducted & supported on the
nurse’s forearm.
● Use the flat surfaces of all fingertips to palpate the four areas of
the axilla.
11. Palpate the breast for masses, tenderness, and any discharge from the
nipples.
12. Palpate the areola and the nipples for masses.
● Compress each nipple to determine the presence of any discharge.
If discharge is present, milk the breast along its radius to identify the
discharge-producing lobe.
● Assess any discharge for amount, color, consistency, and odor.
● Note any tenderness on palpation.

13. Teach the client the technique for breast self-examination.

14. Document findings in the client record.

TOTAL

COMMENTS: GRADE:

Student’s Signature Clinical Instructor’s Signature

 Nursing Skill: ASSESSING THE HEART AND CENTRAL VESSELS

Name:
Date:

Able to
Able to Unable to
Skill Assessment Perform w/
Perform Assistance Perform
3 2 1
1. Assemble equipment.
● Stethoscope
● Centimeter ruler

Procedure
1. Introduce self & verify the client’s identity. Explain to the client what
you are going to do, why it is necessary, and how the client can
cooperate.
2. Perform hand hygiene and observe other appropriate infection control
procedures.

3. Provide for client privacy.

4. Inquire if the client has any history of the following:
● Family history of incidence & age of heart disease, high
cholesterol levels, high BP, stroke, obesity, congenital heart
disease, arterial disease, hypertension, & rheumatic fever.
● Past history of rheumatic fever, heart murmur, heart attack,
varicosities, or heart failure.
● Present symptoms indicative of heart disease.
● Presence of diseases that affect heart.
● Lifestyle habits that are risk factors for cardiac disease.

Assessment
5. Simultaneously inspect and palpate the precordium for the presence
of abnormal pulsations, lifts, or heaves.
6. Auscultate the heart in all four anatomic sites: aortic, pulmonic,
tricuspid, and apical (mitral).
7. Palpate the carotid artery. Use extreme caution.

8. Auscultate the carotid artery.

9. Inspect the jugular veins for distention.
● The client is placed in a semi-Fowler’s position, with the head
supported on a small pillow.
10. If jugular distention is present, assess the jugular venous pressure.
● Locate the highest visible point of distention of the internal jugular
vein.
● Measure the vertical height of this point in centimeters from the
sternal angle, the point at which the clavicles meet.
● Repeat the steps above the other side.

11. Document findings in the client record.

TOTAL

COMMENTS: GRADE:

Student’s Signature Clinical Instructor’s Signature

 Nursing Skill: ASSESSING THE PERIPHERAL VASCULAR SYSTEM

Name:
Date:

Able to
Able to Unable to
Skill Assessment Perform w/
Perform Assistance Perform
3 2 1
1. Introduce self & verify the client’s identity. Explain to the client what
you are going to do, why it is necessary, and how the client can
cooperate.
2. Perform hand hygiene and observe other appropriate infection control
procedures.

3. Provide for client privacy.

4. Inquire if the client has any history of the following:

● Heart disorders, varicosities, arterial disease, & hypertension
● Lifestyle patterns, specially exercise patterns, activity & tolerance
● Smoking and use of alcohol

Assessment
5. Palpate the peripheral pulses on both sides of client’s body
individually, simultaneously (except the carotid pulse), &
systematically to determine the symmetry of pulse volume.
6. Inspect the peripheral veins in the arms & legs for the presence
and/or appearance of superficial veins when limbs are dependent and
when limbs are elevated.
7. Assess the peripheral leg vein for signs of phlebitis.
● Inspect calves for redness & swelling over vein sites.
● Palpate the calves for firmness or tension of the muscles, edema
over the dorsum of foot, and areas of localized warmth.
● Push the calves from side to side. Firmly dorsiflex the client’s foot
while supporting entire leg in extension, or have the person stand or
walk.

8. Inspect the skin of the hands and feet for color, temperature, edema,
and skin changes.
9. Assess the adequacy of arterial flow if arterial insufficiency is suspected.

10. Document findings in the client record.

TOTAL

COMMENTS: GRADE:

Student’s Signature Clinical Instructor’s Signature

 Nursing Skill: ASSESSING THE ABDOMEN

Name:
Date:

Able to
Able to Unable to
Skill Assessment Perform w/
Perform Assistance Perform
3 2 1
1. Prepare equipment:
● Examining light
● Tape measure
● Stethoscope
2. Inquire client’s history of bowel habits, change in appetite, specific abdominal
signs and symptoms, hematemesis, previous and current problems and
treatment.
3. Position client in supine position with the arms placed comfortably at
the sides. Place small pillows beneath the knees and the head to reduce
tension in the abdominal muscle. Expose only the client’s
abdomen from the chest line to the pubic area.
4. Inspection.
● Observe for contour and symmetry. If distention is present,
measure the abdominal girth with a tape measure.
● Observe abdominal movements associated with respiration,
peristalsis or aortic pulsation.
● Observe for scars, striae, rashes, and lesions.
5. Auscultation. Auscultate the abdomen before percussing and palpating to
avoid stimulating intestinal activity and altering bowel sounds.
● In all quadrants, listen for active bowel sounds-irregular gurgling
noises occurring about 5-20 seconds. Note frequency, pitch, and
duration of sounds.
● Auscultate for bruits over the abdominal aorta and the renal, iliac,
and femoral arteries.
6. Percussion.
● Percuss all quadrants. Note areas of tympani or dullness. Use a
systematic pattern. Begin in the lower left quadrant, proceed to the
lower right quadrant, the upper right quadrant, and the upper left
quadrant.
● Percuss liver size starting in the midclavicular line below the level of
the umbilicus and moving upward and downward to locate the liver
border.
● Strike at the costovertebral angles, noting tenderness or pain.
7. Palpation.
● Abdomen. Palpate lightly in all quadrant and follow with deep
palpation. Assess organ location and abdominal muscle tone.
Note unusual masses, pulsations, tenderness or pain.
● Kidney. Palpate kidneys bimanually slightly below the umbilicus.
Note size, shape, and tenderness.
● Abdominal aorta. Palpate contour and pulsations.
● Lymph nodes. Palpate inguinal and femoral areas bilaterally. Note
enlargement.
8. Position client comfortably in bed after assessment.
9. Document findings in the client record.
TOTAL

COMMENTS: GRADE:

Student’s Signature Clinical Instructor’s Signature

 Nursing Skill: ASSESSING THE MUSCULOSKELETAL SYSTEM

Name:
Date:

Able to
Able to Unable to
Skill Assessment Perform w/
Perform Assistance Perform
3 2 1
1. Introduce self & verify the client’s identity. Explain to the client what
you are going to do, why it is necessary, and how the client can
cooperate.
2. Perform hand hygiene and observe other appropriate infection control
procedures.

3. Provide for client privacy.

4. Inquire if the client has any history of the following:
● Muscle pain: onset, location, character, associated phenomena, &
aggravating & alleviating factors
● Any limitations to movements or inability to perform ADLs
● Previous sports injuries
● Any loss of function without pain

Assessment
5. Inspect the muscles for size.
● Compare each muscle on one side of the body to the same
muscle on the other side. For any apparent discrepancies,
measure the muscles with a tape.

6. Inspect the muscles & tendons for contractures.

7. Inspect the muscles for tremors.
● Inspect any tremors of hands & arms by having the client hold
arms out in front of the body.
8. Palpate muscles at rest to determine muscle tonicity.
9. Palpate muscles while the client is active & passive for flaccidity,
spasticity, and smoothness of movement.
10. Test muscle strength. Compare the right side with the left side.

11. Inspect the skeleton for normal structure and deformities.

12. Palpate the bones to locate any areas of edema or tenderness.

13. Inspect the joint for swelling.

14. Assess joint range of motion. Ask the client to move selected body
parts.
15. Document findings in the client record.

TOTAL

COMMENTS: GRADE:

Student’s Signature Clinical Instructor’s Signature

 Nursing Skill: ASSESSING THE NEUROLOGIC SYSTEM

Name:
Date:

Able to
Able to Unable to
Skill Assessment Perform w/
Perform Assistance Perform
3 2 1
1. Note the components of the neurological examination.
a. Mental status
b. Cranial Nerve function
c. Cerebellar function
d. Motor function
e. Sensory function
f. Reflexes
CRANIAL NERVES ASSESSMENT
CN I – Olfactory Nerve
o With the client’s eyes closed, present various odors occluding one
nostril at a time. Note client’s ability to identify the odor.
CN II – Optic Nerve
o Test Visual Acuity
o Visual Fields of Gaze
CN III, IV, VI – Oculomotor, Trochlear, Abducens
o 6 Cardinal Fields of Gaze
o Assess PERRLA
CN V – Trigeminal
o Motor – Assess client’s ability to chew and strength to bite
o Sensory – Assess the client’s ability to distinguish light tough and
pain. Light stroke clients face with a wisp and gently prick the skin
with sharp object
CN VII – Facial
o Motor – Assess symmetry of facial movements as the client
smiles, frowns, grimaces, clenches his teeth and so forth.
o Sensory – Ask the client to identify various distinct flavors placed
on the anterior two thirds of the tongue
CN VIII – Vestibulocochlear
o Vestibular branch – perform the Romberg test to evaluate
equilibrium.
o Cochlear branch- Assess client’s ability to hear spoken words
CNIX – Glossopharyngeal nerve
o Motor – Ask the client to move tongue from side to side and up
and down. Test for gag reflex by gently touching the posterior
pharyngeal wall with a tongue blade.
o Sensory – Apply tastes on posterior tongue for identification
CN X – Vagus Nerve
o Ask the client to swallow and note swallowing and vocal cord
movements
CN XI – Accessory Nerve
o Assess strength of the sternocleidomastoid and upper trapezius muscles
by asking the client to move the head against resistance
of your hand.
CN XII – Hypoglossal
o Test strength and articulation of tongue
2. Cerebellar function
● Assess posture, gait, an balance. Have the client walk forward
and backward in a straight line.
● Assess the coordination in the lower extremities by having the
client tap the toes and slide the heel down the contralateral skin.
3. Motor function
● Muscle mass. Assess symmetry and distribution distal and
proximally and circumference of the extremities.
● Tone. Evaluate the resistance of muscles in response to the
passive motion during flexion and extension of extremities.
● Strength. Assess hands and squeeze muscle strength in each
extremity against resistance during flexion and extension
● Observe for involuntary movements
4. Sensory function
● Light touch – With client’s eyes closed, have the client indicate
response to cotton wisp lightly stroked on the skin. Compare
bilaterally and distal proximal
● Pain – repeat the pattern of light touch assessment, using a
sterile sharp object to elicit sharp sensation.
● Stereognosis – ask the client to identify small object placed in
his hands, one at a time
● Graphesthesia – ask the client to identify a number that is trace
in his palm with your finger tip.
5. Deep Tendon Reflexes – Striking with a reflex hammer, compare
reflex amplitude bilaterally.
● Brachioradialis
● Biceps
● Triceps
● Patellar
● Achilles Ankle Jerk
6. Superficial Cutaneous Reflexes
● Abdominal
● Cremasteric
● Plantar/Babinski

7. Document findings in the client record.

TOTAL

COMMENTS: GRADE:

Student’s Signature Clinical Instructor’s Signature

 Nursing Skill: ASSESSING THE MALE GENITALS AND INGUINAL AREA

Name:
Date:

Able to
Able to Unable to
Skill Assessment Perform w/
Perform Assistance Perform
3 2 1
1. Assemble equipment.
● Clean gloves
Procedure
1. Introduce self & verify the client’s identity. Explain to the client what
you are going to do, why it is necessary, and how the client can
cooperate.
2. Perform hand hygiene and observe other appropriate infection control
procedures.
3. Provide for client privacy. Request the presence of another person if
desired, required by agency policy, or requested by client.
4. Inquire if the client has any history of the following:
● Usual voiding patterns & any changes, bladder control, urinary
incontinence, frequency, or urgency
● Abdominal pain
● Symptoms of STDs
● Swellings that could indicate the presence of a hernia
● Family history of nephritis, malignancy of the prostate, or
malignancy of the kidney
5. Cover the pelvic area with a sheet, or drape at all times when not
actually being examined.
Assessment
6. Inspect the distribution, amount, and characteristics of pubic hair.
7. Inspect the penile shaft and glans penis for lesions, nodules,
swellings and inflammation.
8. Inspect the urethral meatus for swelling, inflammation, and discharge.
● Compress or ask the client to compress the glans slightly to open
the urethral meatus to inspect it for discharge.
● If the client has reported a discharge, instruct the client to strip the
penis from the base to the urethra.
9. Palpate the penis for tenderness, thickening, and nodules.
10. Inspect the scrotum for appearance, general size, and symmetry.
● To facilitate inspection of scrotum during a physical examination,
ask the client to hold the penis out of the way.
● Inspect all skin surfaces by spreading the rugated surface skin and
lifting the scrotum as needed to observe posterior surfaces.
11. Palpate the scrotum to assess the status of underlying testes, epididymis,
and spermatic cord. Palpate both testes simultaneously
for comparative purposes.
12. Inspect both inguinal areas for bulges while the client is standing, if
possible.
● First, have the client remain at rest.
● Next, have the client hold his breath and strain or bear down, as
though having a bowel movement.
13. Palpate hernias.
14. Document findings in the client record.
TOTAL

COMMENTS: GRADE:

Student’s Signature Clinical Instructor’s Signature

 Nursing Skill: ASSESSING THE FEMALE GENITALS AND INGUINAL AREA

Name:
Date:

Able to
Able to Unable to
Skill Assessment Perform w/
Perform Assistance Perform
3 2 1
1. Assemble equipment.
● Clean gloves
● Drape
● Supplemental lighting, if needed
Procedure
1. Introduce self & verify the client’s identity. Explain to the client what
you are going to do, why it is necessary, and how the client can
cooperate.
2. Perform hand hygiene and observe other appropriate infection control
procedures.
3. Provide for client privacy. Request the presence of another person if
desired, required by agency policy, or requested by client.
4. Inquire if the client has any history of the following:
● Age at onset of menstruation
● Last menstrual period (LMP)
● Regularity of cycle, duration, amount of daily flow, & whether
menstruation is painful
● Incidence of pain during intercourse
● Vaginal discharge
● Number of pregnancies
● Number of live births
● Labor or delivery complications
● Urgency & frequency of urination at night
● Blood in urine
● Painful urination
● Incontinence
● History of STDs, past and present

5. Cover the pelvic area with a sheet, or drape at all times when not
actually being examined. Position the client supine, with feet elevated on
the stirrups of an examination table. Alternately, assist the client into the
dorsal recumbent position with knees flexed and thighs
externally rotated.
Assessment
6. Inspect the distribution, amount, and characteristics of pubic hair.
7. Inspect the skin of the pubic area for parasites, inflammation,
swelling, and lesions. To assess pubic skin adequately, separate the labia
majora & labia minora.
8. Inspect the clitoris, urethral orifice, and vaginal orifice when
separating the labia minora.
9. Palpate the inguinal lymph nodes.
10. Document findings in the client record.
TOTAL

COMMENTS: GRADE:

Student’s Signature Clinical Instructor’s Signature

 Nursing Skill: ASSESSING THE RECTUM AND ANUS

Name:
Date:

Able to
Able to Unable to
Skill Assessment Perform w/
Perform Assistance Perform
3 2 1
1. Assemble equipment.
● Clean gloves
● Water-soluble lubricant
Procedure
1. Introduce self & verify the client’s identity. Explain to the client what you
are going to do, why it is necessary, and how the client can cooperate.
Because digital examinations can cause apprehension and
embarrassment in the client, it is important to help the client relax by
encouraging the client to take deep breaths and informing about
potential sensations such as feelings of defecation or passing gas.
2. Perform hand hygiene and observe other appropriate infection control
procedures.
3. Provide for client privacy. Drape the client appropriately to prevent the
exposure of body parts.
4. Inquire if the client has any history of the following:
● Bright blood in stools, tarry black stools, diarrhea, constipation,
abdominal pain, excessive gas, hemorrhoids, or rectal pain
● Family history of colorectal cancer
● When last stool specimen for occult blood was performed, and
the results
● For males, if not obtained during the genitourinary examination,
any signs or symptoms of prostate enlargement
5. Position the client.
● In adults, a left lateral or Sim’s position with the upper leg acutely
flexed is required for the examination.
● For females – a dorsal recumbent position with hips externally
rotated & knees flexed or a lithotomy position may be used
● For males – a standing position while the client bends over the
examining table may also be used
Assessment
6. Inspect the anus & surrounding tissue for color, integrity, and skin
lesions. Then, ask the client to bear down as though defecating.
● Describe the location of all abnormal findings in terms of a clock,
with the 12 o’clock position toward the pubic symphysis.
7. Palpate the rectum for anal sphincter tonicity, nodules, masses, and
tenderness.
8. On withdrawing the finger from the rectum & anus, observe it for
feces. If ordered, perform a test for occult blood on the stool.
9. Document findings in the client record.
TOTAL

COMMENTS: GRADE:

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