The document provides guidance for conducting a patient assessment. It outlines the steps to check safety, introduce oneself, verify patient identification, check for allergies and pain levels, explain the observations to be taken, and conduct checks of airway, breathing, circulation, disability, exposure, and skin. It describes communicating the patient's NEWS score and escalating care if needed. The assessment is to be conducted with hand hygiene and ensuring privacy, dignity, and patient understanding throughout.

1. ASSESSMENT
Check SAFETY
Close door, curtain or window for privacy
Hand Hygiene
Ensure hand washing 7 steps as per who guideline for 30 sec
Introduce self and role
Preferred Name (pt. name)
Wrist band check
Pt say their name and DOB, hospital number or address if community based
Look at wristband and check against the admission paperwork
Allergy and reaction
Latex allergy
Checks pain and comfort
Score pain 0-10 if with pain
Check if they know why they’re admitted
Offer repositioning of comfortability
State you are doing observations (BP, PR, RR, Temp, O2)
Checks equipment if cleaned and calibrated
CHECK ABCDE
Airway – no obstruction
Breathing – breathlessness, cyanotic, using of accessory muscle, sound of breathing?
(wheeze,crackles) OBS: respirations (1min) and oxygen saturations
(record OBS on NEWS CHART)
Circulation – capillary refill <2sec, cyanotic hands or feet?, limb temperature warm or cold?
OBS: Pulse rate -> blood pressure (record OBS on NEWS CHART)
Disability – Alert, Voice, Pain, or Unconscious (AVPU) (record on NEWS CHART)
Exposure – (no need to check patient skin, ASK THE EXAMINER regarding SKIN) no wound,
bruises, pressure sore OBS: Temperature (record OBS on NEWS CHART)
CORRECT NEWS SCORE/GCS/PHQ9 SCORE
State NEWS score to patient and state when are you going to redo it.
Escalating to doctor or nurse in charge as per NEWS SCORE
Checking understanding
Buzzer and bed on the lowest part
Verbal Documentation
Hand Hygiene

2. SCRIPT FOR ASSESSMENT:
Scene is safe for me to approach
Close curtains or doors for privacy and dignity
Hand washing USING 7 STEPS AS PER WHO GUIDELINES for 30 sec (dry hands before approaching pt)
Hi My name is _______, I am your nurse for today
May I know your name please?
Is it alright if check your wristband?
Could you please confirm your full name and date of birth please? (check it against the admission
paper)
Do you have any allergies?
YES – What are you allergic with and what is the reaction?
Thank you for giving me that information, I will make sure you will not get any medication containing
Penicillin.
Do you have any pain? Can you score it from 0-10 0 as no pain 10 as very painful.
Do you know why you are here (pt name). (If pt is unable to answer, orient him to time and place)
I am here today to do your observations and this will consist of respirations, oxygen level, pulse rate,
blood pressure and temperature, will that be alright?
I will just grab the OBS machine and will come back to you. Here is the call bell if you need anything
else.
The OBS machine has been cleaned and calibrated in the last 24 hours and I am happy to use it.
(Hand gel before going back to patient)
Hi (pt name), I’ll be starting getting your OBS now.
First I can see that there is NO obstruction on the pt’s airway and can breathe with ease (AIRWAY),
patient is not using any accessory muscle, not showing breathlessness, not generally cyanotic and no
wheezing.
I’ll be checking patient’s respirations for 1 minute while I do the oxygen saturation. (BREATHING)
Is it alright if I pop this probe on one of your fingers just to check your oxygen level? (No nail polish,
leave the probe for one minute while counting resps)
AFTER 1 MINUTE
I did not tell you that I will be checking your respirations for 1 minute for me to get accurate result.
I’ll be taking your pulse rate then blood pressure. (CIRCULATION)
Patient’s capillary refill is <2sec, no cyanosis noted, limbs are warm to touch.
I’ll be checking your pulse now for 1 minute.
AFTER 1 MINUTE
I’ll be taking your blood pressure now and which arm do you want me to attach this?
You might feel tightness while we the machine’s taking your blood pressure.
Patient is alert and conscious, oriented to time and place. (DISABILITY)
Lastly, I’ll be taking your temperature. (EXPOSURE) Pt. doesn’t have any hearing aid or infection.
Ms. Examiner may I ask if the patient has bed sore? (examiner: NO) I can see her as well pt doesn’t
have any visible wounds or bruises.
*FOR GCS*
Can you please raise both of your arms and resist it when I’m pushing it downward (NORMAL
POWER)
Can you please lift your Right leg and resist when I’m pushing it downward (NORMAL POWER)
Can you please lift your left leg and resist when I’m pushing it downward (NORMAL POWER)

3. (Pt. name) I am done taking the observations and I’ll be documenting it now. Here is the call bell if
you need me. (COMPUTE NEWS SCORE)
Ms. Examiner, the NEWS SCORE is _____, I will / will not escalate it and I will retake it after (as per
NEWS POLICY).
HAND HYGIENE when going back to patient.
Hi, Pt name, I am now done documenting, everything is alright (state if any obs are elevated) and I
will redo your OBS after 12/4/6 hours/ 30min.
Before I leave do you have any concerns?
(IF YES – address it)
(IF NO – reassure)
Here is the call bell if you need anything.
I’ll put the bed rails up for safety and bed at its lowest position.
FINAL HAND HYGIENE