Clinical Assessment E-portfolio

Appendix E: Clinical Assessment E-portfolio Part B: Head-to-toe assessment guide for PEPAE

Students are required to complete a full head-to- toe assessment on a patient they have been caring for whilst on clinical placement. This assessment must be supervised by either a CNE or preceptor, must be signed once completed and then attached as an appendix as part of your PEPAE submission. Please note that this document (appendix E) does not count towards the overall wordcount for this assessment. Once you have completed your patient head-to-toe assessment students, should sit with their CNE/preceptor and identify the patient’s priority problems, documenting these on appendix F.

Directions for CNE/preceptor: Please consider the students Scope of Practice when assessing their head-to-toe assessment. All points highlighted bold must be completed without prompting. All points highlighted red are outside of the scope of practice of a first year, first semester MNSC student. It is advised that CNE/preceptor read the UoM students Scope of Practice document when preparing to assess the student.

Nursing Physical Assessment Using a Body System Approach CNE/Preceptor assessed


Identify indication or rationale for medication administration (Oral)

·         Confirm patient identity

·         Determines need to undertake a nursing physical assessment

·         Identify appropriate timing for performing the assessment

Therapeutic relationship

·         Initiate communication by introductions and clarification of patient’s immediate needs and problems

·         Clarify patient knowledge and provides education where necessary

·         Explain actions and potential discomfort at all stages of the procedure

·         Gain patient consent

Assess patient

·         Assess patient comfort and provides analgesia where appropriate

·         Performs a rapid visual assessment of the patient and their environment for important cues.

The primary survey below may assist with this rapid review and should be performed every time you attend to your patient but is not to be included in your PEPAE submission.

Primary survey

Airway – Is the airway clear?

·         Listen for noisy or obstructed breathing

·         Feel for airflow over the mouth

·         If indicated, assesses whether artificial airway is patent and secure (e.g. Guedel, nasopharyngeal, tracheostomy, endotracheal tube, non-invasive mask)

Breathing – Is the patient breathing spontaneously?

·         Look for rise and fall of the chest

Circulation – Does the patient have adequate circulation?

·         Observe skin colour

·         Feel for a pulse

Disability – What is the patient’s level of consciousness?

·         Determine if the patient is alert, responsive to voice, responsive to pain, or unresponsive (unconscious)

Exposure– Performs a quick head-to-toe scan of the patient and their environment:

·         Does the patient look well, sick or critical?

·         What treatments are in progress and how might these affect your assessment findings (e.g. medications, infusions, oxygen)?

·         What monitoring devices or equipment are attached to the patient or in their environment, what do they reveal?


Performs Hand Hygiene

·         Performs social handwash

·         Adheres to ‘5 moments for hand

·         Wear appropriate PPE

Gather equipment

·         Blue/black pen, relevant documentation

·         Penlight torch

·         Pulse oximeter

·         Stethoscope

·         Sphygmomanometer

·         Thermometer

Prepare Equipment

·         Consider privacy and appropriateness of setting (Inclusion of family, friends, NOK)

·         Position patient comfortably

Perform Clinical Procedure- Neurological

·         Assesses level of consciousness and mental status

o    If indicated, performs a focused neurological assessment including Glasgow Coma Scale, pupil size and reaction, limb strength and vital signs

o    If indicated, performs a mental state assessment

·         Assesses for pain or discomfort

o    If indicated, performs a focused pain assessment using a pain assessment tool


Perform Clinical Procedure- Cardiovascular

·         Inspect and palpates skin colour, temperature and capillary refill

·         Palpates peripheral pulses for rate, rhythm and strength

·         Measure blood pressure

·         Auscultate apical pulse and heart sounds

·         Palpate calves for tenderness

·         Palpate for oedema in feet and dependent areas (e.g. sacrum)

o    If indicated, performs a focused cardiovascular assessment


Other considerations: Within SoP

·         Observe and interprets the electrocardiogram (ECG)

·         Observe for permanent pacemaker (PPM), pacing wires, external pacing, implantable defibrillator

·         Observe for compression stockings and sequential compression devices

Perform Clinical Procedure- Respiratory

·         Inspect chest and work of breathing

·         Measure respiratory rate, rhythm and depth

·         Assess ability to cough; examines sputum if indicated

·         Auscultate lung sounds

·         Measure oxygen saturation

o    If indicated, performs a focused respiratory assessment


Other considerations: Within SoP

·         Observe for intercostal catheters and underwater seal drains.

·         Is catheter/drain swinging, bubbling and/or draining freely? Is there wall suction?

·         Identify the colour and volume of any drainage from chest drains

Perform Clinical Procedure- Gastrointestinal

·         Inspect the abdomen for symmetry, masses or distension

·         Auscultate for bowel sounds

·         Palpate the abdomen lightly noting any tenderness, guarding or rigidity; feels for any masses or pulsations

·         Assess most recent and frequency of bowel action

o    If indicated, performs a focused abdominal assessment

·         Assess mucous membranes (looking for redness, ulceration, dental cavity)

·         Assess for nausea and vomiting

·         Assess weight (recent gain/loss)


Other considerations: Within SoP

·         Check if the patient is nil by mouth (NBM)? If oral diet: normal soft, smooth/minced? Assesses percent of meal eaten. Is the patient on a food and/or fluid balance chart

·         Observe for enteral feeding tubes (e.g. nasogastric or orogastric tube (NGT/OGT)), percutaneous endoscopic gastrostomy (PEG) tube. Continuous, intermittent or bolus feeds? Central or parenteral total parenteral nutrition (TPN)?

·         Observe for stomas. Pink? Active? Consistency and volume of effluent. Intact faecal containment device? Integrity of surrounding skin?

Perform Clinical Procedure- Renal

·         Observe current intake and output, 24-hour fluid balance.

·         Assess and interpret fluid status

o    If indicated, measures and compares daily weight to determine fluid balance

·         Measure and observes urine output, colour, presence of sediment

o    If indicated, palpates bladder for distension

o    If indicated, performs urinalysis


Other considerations: Within SoP

·         Observe and interprets blood urea and electrolytes

·         Assess and interprets fluid status

·         Observe for urostomy, indwelling urinary catheter (JDC), suprapubic catheter (SPC)

·         Observe for peritoneal or haemodialysis. Arteriovenous fistula thrill/ bruit? Fluid and sodium restrictions?

Perform Clinical Procedure- Musculoskeletal

·         Inspect major joints for range-of-motion

·         Assess muscle strength and compares sides

·         Observe safe use of mobility aids

·         Observe ability to transfer and mobilise

o    If indicated, perform a focused musculoskeletal assessment

Perform Clinical Procedure- Integumentary

·         Inspect and palpate the skin for general colour, temperature, moisture and turgor and capillary refill

·         Inspect and palpate for signs of pressure injury such as non-blanchable redness, localised heat, oedema and induration

·         Observe any wounds, dressings and drains for warmth, redness, swelling, exudate and odour

o    If indicated, performs a focused wound assessment (see Chapter 26t) If indicated, performs a focused skin


Other considerations: Within SoP

·         Observes invasive lines (e.g. peripheral intravenous catheter (IVG), central venous catheter (CVC), peripherally inserted central line (PICC), Vascath, Portacath)




Perform Clinical Procedure- Analysing data

·         Compare assessment findings with patient’s baseline assessment data

·         Analyse for important changes or trends over time

Clean and dispose of equipment appropriately

·         Dispose of used equipment in appropriate reciprocal

·         Place call bell within reach

·         Leave room clean and clear of clutter

·         Perform hand hygiene

·         Clean any equipment used

Complete Documentation

·         Documents assessment findings in patient’s healthcare record following a structured nursing assessment framework

·         Reports any significant abnormal data to senior nurse and/or medical officer



Signed by CNE/Preceptor: ­­­­­­­­­­­­­­­­……………………………………………………………………….   Date………………………………………………