• 20 mins
  • New NMC TOC 2021 - ASSESSMENT
  • NEWS 2 Part 2 | How to complete the NEWS Chart? | OSCE
  • I am checking for scene safety, I can see there is no slips or fall hazards, I am happy to proceed.
  • I will make sure the curtains are closed, the door is closed in order to provide the privacy and dignity of my patient. 
  • I am cleaning my hands with alcohol hand rub according to WHO guidelines. Palm to palm, fingers interlace, palm to fingers interlaced, fingers interlocked, left and right thumb, fingertips.
  • Introduces self to person, check id
    • Hello, I am Vicky, I am your nurse today. I am here to do an A to E nursing assessment. Is that okay?
    • Before I proceed, can you tell me your full name please? What can I call you?
    • Can you tell me your date of birth?
    • Can I confirm that with your id band? (Name, date of birth, hospital number)
    • That matches the record
  • I can see that you have a white wristband, do you have any allergies that you are aware of at all?
  • Perfect, so you have got the right wristband.
  • Gains consent and explains the reason for the assessment.
    • “[Preferred name], I will be taking a set of observations, which includes your blood pressure, respiratory and pulse rate, temperature and oxygen saturation. Then I will ask you a couple of questions regarding your activities of daily living so we could plan for your care. Is that alright?”
  • I can see that there are a pair of glasses, are they yours?
  • Do you need it during the assessment?
  • alright, I will just put it here so that you can reach it if you need it.

  • “Are you comfortable with your position? 
  • “This assessment will take around 10-15 minutes, do you want to go to the toilet first?”
  • “If in the middle of the assessment, you will feel uncomfortable, don't hesitate to tell me, okay? Then we will continue with the assessment when you feel better”

  • Airway
    • I'm going to start with your airway
    • I can see you're clearly talking to me with no difficulty, so I can say that your airway is clear, with no form of visual obstructions.
  • Breathing
    • Next, I'm going to move on to your breathing, can you take a deep breath for me please.
    • For breathing, there are no audible respiratory noises, such as wheeze and stridor. I can see from distance that you are breathing with ease, you are not using your accessory muscles and no see-saw breathing is noted.
    • Have you been experiencing a cough at all?
    • You don't have any difficulties in your breathing at all? 
    •  Oxygen saturation
    • Can I put my hands on your chest to assess your air entry.
    • I can say that you have an equal air entry.
  • Circulation
    • Now I'm going to move on to c, which is circulation.
    • I'm going to check your capillary refill, I will now raise your hand to the level of the heart, and press it for two to five seconds, I can see the colour came back with in 2 seconds.
    • I will now check your radial pulse, I will need you to relax and keep quiet for two minutes.
    • I finished taking your pulse, it is 78, which is in regular rhythm and the strength is also normal.
    • I have also taken your breathing rate, which is 18, and the rhythm is regular and the depth is normal.
    • I will now check your blood pressure. I can that this arm have no swelling, no cannula or fistula, and the skin is intact, I'm happy to use this arm. It covers around 80 percents of the arm and place 2-3 cm apart from the elbow. 
    • Your blood pressure is xxxx, which is normal. 
    •  Can I place my hands over your limbs to check for perfusions?
    • The perfusion on your upper and lower limbs are normal, they are warm to touch, and no signs of pallor.
  • Disability
    • As for disability, my patient consciousness level is alert and orientated. 
    • Are you in pain? (if yes, “When did you last take your pain medication? From 1-10, with 1 as the lowest and 10 as the highest, how would you rate your pain? Do you want me to get pain medication for you?”)
    • You can do some deep breathing exercises at the moment to relieve your pain, I will review your drug chart as soon as possible to see if I can give you anything at this point.
    • Also, I am happy to help if you need reposition, are you comfortable at the moment?
    • How is your bowel and urine? Do you have any problem with that?
    • Do you have any problems going to the loo?
    • blood sugar
  • Exposure
    • I can see there is no hearing aids, no signs of infections or discharges, I'm happy to use this ear
    • Your temperature is fine, it is 37.0 degree celsius.
    • Do you have any rashes, bruises or injuries in any part of your body?
    • In your past medical history, you have ...
    • Is there any other conditions that we should take note of?
  • Do you smoke or drink at all?
  • Mobility
  • I have calculated your news, which is the national early warning score that helps us to monitor your condition to see any signs of deterioration, and what to do next. You are news one. I will monitor your four hourly. And I will escalate to doctors if there is any other clinical changes. I will come back later for your pain killers. Do you have any questions or concerns before I go? Here is your call bell, let me know if you need anything.
  • I will dispose the equipment appropriately and clean my hands using alcohol hand rub according to WHO guidelines.