OSCE PREPARATION PRACTICE GUIDE:

DEPARTMENT OF NURSING

BNUR 134: HEALTH ASSESSMENT SKILLS CHECK LIST

September 2022

Student name : Ambrose Kibet Kirui

Student ID : Bsnlmr374422

Student client(s) assessed-ID : Bsnlmr375822

Student client(s) name : Frankline Michael

Procedure/ skill Findings Date/Sign

Preparation: done or not done I went and scrubbed my hands clean.

 Self Evaluation of procedures and potential

factors affecting vital signs. 3/11/2022

 Environment Made sure the room was clean and private.

Possessing sufficient square footage and

air flow.

 Client After explaining and gaining your consent,

relax and breathe normally while I take

your vital signs. Ask if he's eaten or drank

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in the past 30 minutes. Before the starting

the procedure, I asked him to relax for five

minutes.

Initial assessment 3/11/2022

 General appearance Active, young, interactive, healthy and

upright posture

 Vital signs

Blood pressure- 117/68 mm Hg

SpO2- 96%

Temperature- 36.5°C

Pulse rate- 72 beats per minute

Respiratory rate (RR)- 12 beats per minute

 Measurements: height, Height- 177.5 cm

weight, BMI Weight- 72 kg

BMI= Weight (kg) / Height (m)2

=72 (kg)/(1.775 *1.775)(m)2

=22.85 hence normal weight

Comprehensive health History 3/11/2022

Chief Complaint No chief complaint

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Source and Setting I assess the client at the hospital skills

laboratory

History of Present Illness The client denies having any current

illness

Past Medical History The client denies having any medical

history

Surgical History No surgical history

Medication The client denies using any medications

Allergies No history of adverse reactions to any

prescribed medications. No known

allergies to pollen, dust, shellfish, or any

other allergens.

The client has both parents and one

Family History brother; Father-56 years; Mother- 52

years; Brother- 8 years

The client is20-year-old

Social History university student. Homebound patient

feels safe and cared for. Patient denies

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smoking. Patient denies drug use. Daily

workouts. Patient eats largely home-

cooked meat and vegetables. Sexually

active and delighted with his lover.

Interview techniques identified I introduce myself and explain the 3/11/2022

 Introductory phase interview to the client. Ensure client

comfort before asking questions. trusting

Protecting privacy

 Type of questioning used Listening to and monitoring nonverbal

signs validates the client's knowledge and

concerns through critical thinking

abilities.

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 Method of termination

Summarizes working phase data,

evaluates client’s issues and goals, and

develops a solution.

System to be evaluated: for each of Findings Date/sign

the aspects state the areas assessed 10/11/2022

HEENT system: No scars, bumps, or lumps can be felt on 10/11/2022

Subjective data: the head. Hair feels and grows the same

Do you get frequent or severe everywhere.

headaches? Good eyesight. Clear, exudates-free

Any past history of head injury? conjunctivae.

Do you frequently get dizzy? The ear canal, pinna, and tragus are

Do you have any neck pain, swelling, without pain. Normal tympanic

or lumps? membranes are equipped with potent light

Do you have a history of head or cones. The whispering is audible.

neck surgery? Pink, moist nasal mucosa. The nasal

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septum is central. Visible nostrils.

Pink, moist, healthy throat and mouth

mucosa. Lesion-free tongue moves

symmetrically. No mouth abnormalities or

nodules. Exudates and tonsillar edema are

absent from the pharynx.

Head/ Hair The client's body is covered in a variable 10/11/2022

amount of thick, smooth, and even hair.

Moreover, no infectious or parasite signs

have been detected.

Eye Eyebrows-An even distribution of hair can 10/11/2022

be seen. When asked to lift and lower their

brows, the client responded with equal

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movement on both sides.

Eyelashes-The eyelashes appeared similar

in length and thickness due to their

outward curling and spacing.

Eyelids- There were no presence of

discharges, no discoloration and lids close

symmetrically with involuntary blinks

approximately 15-20 times per minute.

Bulbar had translucent, few-capillary

conjunctiva. White sclera. Pink, glossy,

smooth eyelid conjunctiva. Lacrimal

glands are unharmed. The cornea shows

the iris's finer features. Touching the

client's cornea causes blinking. Each eye

has identical-sized and colored pupils.

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His left and right earlobes match his face. 10/11/2022

Ear The body's auricle and eye's outer canthus

are identical. The auricle can be moved. It

can investigate textures. Pinnas snap back

when folded. The Watch tick test caused

ticking in both ears.

Straight, consistent on both sides, and one 10/11/2022

Nose and sinuses: inspection and color. No leak or flare. Palpation caused

palpation no cuts or suffering.

Throat: thyroid Visible on inspection, glands ascend 10/11/2022

during swallowing.

Oral cavity Pink, moist, and distinct oral mucosa. No

lesions and symmetrical tongue

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movement. The mouth is normal. The

throat is clear of exudates and tonsillar

edema. No glandular disease.

Trachea position Slightly tilted to right.

He has a normal flexion, extension, right

Neck movement
rotation, left rotation and left lateral

flexion

Lymph nodes
Non-palpable, non-tender

10/11/2022

My client has thick, even hair. There were

Documentation no infectious or parasitic signs. Even

eyebrows. The client bowed as instructed.

Curling and spacing made eyelashes

appear the same length and thickness. No

discharges, no discoloration, and lids close

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15-20 times each minute. Face matches

earlobes. Auricle and outer canthus match.

Migrating earlobe. Texture analysis.

Pinnas unfold when folded. Watch tick

tickled ear. Nose and sinuses are straight

and one color. Leak-free. Painless

palpation. Pink, wet mucosa. No tongue

lesions, symmetric movement. Normal.

No exudates or tonsil edema. Non-

glandular. Normal flexion, extension,

rotation, and lateral flexion. Non-tender

lymph nodes

Neuro system: 14/11/2022

Subjective data The client is awake, talks, and knows

Have you experienced any difficulty time, place, and person. Both sides have

swallowing or speaking? 5/5 muscle strength and no motor

Do you have any coordination impairments. Everyone feels. 2+ reflexes

problems? bilaterally. Unaffected brain nerves. No

Do you have any past neurologic cerebellar dysfunction. Healthy memory

history such as spinal cord injury? and cognition.

Have you experienced any recent

falls?

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Mental status: orientation x3 Alert and oriented X 3. Strength of biceps, 14/11/2022

 Speech, triceps, hand grip, finger spread, hip

 Mood and affect, flexion, knee flexion, and knee extension

 GCS 5/5 bilaterally.

Cranial nerves Cranial nerves II–XII were unharmed.

Tandem walking was symmetrical. The

distal extremities still feel acutely.

Proprioception is intact.

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Sensory function: Pain and gentle touch are intact. The gap 14/11/2022

remains two points.

Motor Function: Fitness-trained muscle. 5/5 bilateral 14/11/2022

deltoid, biceps, triceps, quadriceps, and

hamstring strength.

Cerebellar function: Both sides had normal finger-to-nose and 14/11/2022

heel-to-shin tests. Closes eyes and stays

balanced (Romberg). Move frequently.

Average walk. Heel-toe walking shows

coordination.

Reflexes Biceps, brachioradialis, triceps, patellar, 14/11/2022

and Achilles are 2/4 and are bilateral.

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Clone-free. Plantar reflex is downward

bilaterally.

Cardiovascular system: Client denies any chest pain. 14/11/2022

Subjective data The client denies having short of breath.

Any chest pain? One pillow, no cough, no swelling or

Do you ever get short of breath? edema.

(associated with what) No changes on skin color.

How many pillows do you sleep on The client denies nocturia

at night? (orthopnea) Denies having a family history of

Do you have a cough? (describe, cardiovascular disease.

frequency, timing, severity, sputum

production)

Are you frequently fatigued?

(morning or night)

Do you have any swelling or skin

color changes? (edema, cyanosis,

pallor)

How often do you get up at night to

urinate? (nocturia)

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Do you have a past history of cardiac

or cardiovascular events or disorders?

Do you have a family history of

cardiovascular disease?

Pulse 72 beats per minute

Blood pressure 117/68 mm Hg

Inspection: Apical impulse visible 14/11/2022

Both sides have race-appropriate skin

tone.

Same hair on upper and lower extremities

Absence of jugular vein distention (JVD)

Absence of edema

Palpation: Apical pulse is felt above midclavicular 14/11/2022

fifth intercostal region.

Absence of edema

Skin warm and dry

Pulses present and equal bilaterally

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Auscultation: Heartbeats S1 and S2 are heard in a 14/11/2022

regular rhythm.

Carotid pulse is heard

Heart sounds S1 and S2 beat regularly. 14/11/2022

Landmarks

Documentation The chest's exterior shows no lifts, heaves,

or thrills. The palpable but invisible point 14/11/2022

of maximum impulse is the 5th intercostal

gap at the midclavicular line. Normal

heart rate and rhythm. Auscultation finds

no murmurs, gallops, or rubs. S1 and S2

are heard with moderate strength.

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Respiratory rate and oxygen Respiratory rate (RR)- 12 beats per minute

saturation SpO2- 96%

Inspection: 14/11/2022
Regular breathing pattern

Asymmetrical chest enlargement

Absence of cyanosis

Clubbing of fingernails

Palpation Palpation reveals no discomfort or 14/11/2022

tenderness. Warm and dry skin without

crepitus or lumps

Percussion sounds Healthy lung tissue makes clear, low- 14/11/2022

pitched, hollow sounds.

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Auscultation No adventitious sounds emanate from the 14/11/2022

lungs.

Documentation Patient denies chest pain, shortness of 14/11/2022

breath, or coughing. Denies respiratory

issues. Thorax symmetry. 1:2

anteroposterior-transverse ratios. The nose

hears 16 regular, unhurried breaths every

minute. No nasal flaring, retractions, or

auxiliary muscles. Chest raises and lowers

evenly. Pink, dry, and hot skin. Palpating

the anterior and posterior chest shows no

tumors, crepitus, or pain. Lungs can be

heard in all lobes. No adventitious sounds.

Indoor SpO2 99%.

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Gastrointestinal system ( abdomen) The client denies having any 15/11/2022

Subjective data gastrointestinal problem.

Have you ever been diagnosed with a The client denies having any surgery on

kidney, bladder, or gastrointestinal his abdomen.

(GI) problem? No abdominal pain. No difficulty on

Have you ever had surgery on your swallowing.

abdomen?

Do you ever have trouble (dysphagia)

swallowing food or liquids?

Do you have any abdominal pain?

Inspection: Protruding abdomen 15/11/2022

No visible lesions

Intact skin

Auscultation: No bruits. Normal heart sounds are heard 15/11/2022

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Percussion of hollow and Percussion dullness on the left lower 15/11/2022

solid organs anterior chest wall-indicating absence of

splenomegaly

Percussion on the spleen remains

tympanitic

Light palpation Left kidney unpalpable 15/11/2022

The liver is palpable, its edge is more

deep palpation: acute, and it extends medially and

laterally. Rounded right kidney.

Inflammatory colon

Special procedures: The borders between tympany and 15/11/2022

Assessing Possible Ascites dullness relatively constant on percusion

Assessing Possible Appendicitis Pain in the right lower quadrant during

left-sided pressure

Assessing Ventral Hernias The bulge of a hernia appear on raising

both the head and shoulder

Assessing Possible Acute A sharp increase in tenderness with a

Cholecystitis sudden stop in inspiratory effort

constitutes a positive Murphy’s sign of

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acute cholecystitis.

Documentation Protruding abdomen and loud bowel 15/11/2022

motions It is smooth and nontender

without lumps or hepatosplenomegaly.

The liver span is 7 cm at the right

midclavicular line and smooth and

noticeable 1 cm below the right costal

margin. Without a costovertebral angle.

Tenderness (CVA). Murphy’s sign of

acute cholecystitis. Positive ventral hernia.

Possible appendicitis.

Musculoskeletal system This patient has no history of bone trauma, 16/11/2022

Subjective data: illness, infection, injury, or deformity.

Do you have any musculoskeletal

complaints, such as stiffness, muscle Patient reports continuous daily exercise

weakness, discomfort, edema, or of 2 kilometers, five days a week, and is

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redness? able to manage routine daily tasks without

Have you ever had a musculoskeletal any difficulties.

condition like osteoporosis,

osteoarthritis, or rheumatoid arthritis The client denies having any broken bone,

diagnosed? or any type of musculoskeletal injury.

Have you ever had a neurological

issue that prevented you from The client denies having any fracture

properly using your muscles repair.

diagnosed?

Have you ever had any previous bone

or muscle procedures, such as knee or The client is currently using no

hip replacements or fracture repair? medication.

Have you ever suffered from a

muscle, joint, tendon, or ligament

injury, a broken bone, or any other

type of injury?

Are you currently taking any drugs,

herbs, or dietary supplements to

maintain the health of your muscles,

bones, or musculoskeletal system?

Musculoskeletal system assessment 16/11/2022

On inspection: a straight back, good

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balance, and a steady walking pace

Muscles and joints are symmetrical and

deformed or edematous. All joints can

move actively and effortlessly. There is no

spine curve.

On palpation: There is no obvious warmth

or soreness in the muscles, bones, or

joints. 5/5 for muscle strength versus

resistance.

Documentation This patient has no history of bone trauma,

illness, infection, injury, or deformity.

There are no signs of muscle weakening,

joint stiffness, pain, edema, or impaired

function. Patient reports continuous daily

exercise of 2 kilometers, five days a week,

and is able to manage routine daily tasks

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without any difficulties. Both sides have

symmetrical joints and muscles. Upon

examination, there is no edema, deformity,

mass, or redness. Joint palpation without

pain but without crepitus Legs and arms

move easily and fluidly. Strength in the

upper and lower extremities gets a 5/5.

The patient can maintain full muscle

resistance without feeling sore or

uncomfortable.

Genitourinary system 16/11/2022

Specific subjective data Absence of discomfort

Do you have any pain or discomfort

when urinating (dysuria)?

Do you ever experience any urinary Absence of urgency

urgency?

Do you have any leakage of urine

when you cough, sneeze, or jump No leakages

(urinary incontinence)?

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Genitourinary system assessment Urine is clear and pale yellow. 16/11/2022

Absence of discomfort, urgency, or

retention.

Integumentary system: skin, nails 16/11/2022

Specific subjective data The client denies itching.

Are you having problems with The client denies having any skin problem

your skin? and infection.

Does your skin itch? (pruritus)

No history of skin disease

Do you have a history of skin

problems?

Have you ever had a skin infection

or disease?

Integumentary system assessment Skin is warm, dry, clean and intact. Brown 16/11/2022

in color. Well hydrated with normal skin

turgor.

Denies having itchy skin. Unnoticed

lesions.

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Nicely trimmed nails.

The nails are uniform in color and

consistency, smooth, free of pits or

grooves, and spotless.

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