OSCE

PREPARATION
MANUAL
FOR NURSES
OVERVIEW

What is OSCE?

The OSCE is designed to assess your ability to competently apply your nursing or midwifery skills and
knowledge in the UK. It is set at the level expected of nurses and midwives as they enter the
professional (at the point of registration). This means you must show that you are capable of applying
knowledge to the care of patients at the level expected of a newly registered nurse or midwife.

The examination is testing your ability to apply knowledge to the care of patients rather than how well
you can remember and recite facts. All the scenarios and any questions relate to current best practice
and you should answer them in relation to published evidence and not according to local arrangements.

Assessment criteria

The OSCE is made up of six stations, each lasting 15 minutes with an additional five minutes preparation
time. Four stations will be scenario based and relate to the holistic patient centred assessment,
planning, implementation and evaluation stages of nursing and midwifery care. Two stations will be
testing practical clinical skills. Please remember you will have done these nursing or midwifery
competencies many times before. Make sure that you read the station instructions carefully. Do not be
afraid to look at them again if you are unsure. You will not be penalised for this.

Typical skills which may be tested either on their own or within a nursing/midwifery scenario include:

 vital signs
 calculating drug dosages
 intramuscular and subcutaneous injections
 basic life support –cardio-pulmonary resuscitation ( adult, child, baby)
 safe disposal of sharps
 medication administration
 peak flows
 wound care
 hand hygiene

Communication skills

Communication is central to nursing and midwifery practice and will always be assessed during the
OSCE’s. They will assess the full range of communication skills (verbal, nonverbal and written) by
observing the interaction between the candidate and simulated patient (this may be an actor or a
nursing manikin) and also by assessing your nursing or midwifery documentation.
The examiner will assess your approach to the simulated patient all through the examination, and they
will award marks communication skills such as:

 clearly explaining care, diagnosis, investigations and or treatments.

 involving the patient in decision making
 communicating with relatives and health care professionals
 seeking and obtaining informed consent
 active listening
 dealing appropriately with an anxious patient or relatives
 giving clear instructions on discharge
 giving advice on lifestyle, health promotion or risk factors.
 demonstrating compassion and care during communication
 clear documentation which meets current NMC guidelines
 professional behaviour

You should speak to the simulated patient as you would any patient are meeting for the first time. If you
are being assessed using a nursing manikin please remember to verbalises you actions and reasons for
actions in the same way you would with a real patient.

Approach to the patient

 introduce yourself and explain or clarify the purpose of the nursing or midwifery encounter.
 check what the patient wants you to call them
 be polite, respectful, non-judgemental and maintain the patient’s dignity
 be empathic and acknowledge the patient’s emotions or concerns and show sensitivity to any
discomfort.
 be sensitive to personal space – sit at an appropriate distance from the actor and be aware of
their body language. If you move too close and the role player moves back, you are too close
 treat a nursing manikin as you would a real patient.

Explaining and advising

 establish what the patient already knows and or wants to know

 explain clearly what you are going to do and why, so the patient can understand
 remember to always check if the patient has any questions
 offer appropriate reassurance
 do not alarm the patient but you must be able to explain the need for urgent action if it is
required
 always check the patient has understood
 do not routinely over-simplify names for parts of the body. It is reasonable to expect most
people will know common body name such as ‘bladder’, ‘ovary’, ‘womb’ and ‘vein’. If you
doubt a patients understanding, check and alter your approach to meet the patient’s individual
needs. This is an important skill.
 treat a nursing manikin as you would a real patient
Involving patient in management

 respect patient autonomy and help the patient to make a decision based on available
information and advice. This includes competent explaining skills as above
 explain information and its implications so the patient can make as informed choice about any
nursing or midwifery actions.
 check the patient’s understanding and feelings about the proposed nursing or midwifery
interventions. They may not always agree with your proposed plan of care.
 treat a nursing manikin as you would a real patient

Nursing Assessment

You should be able to undertake an accurate nursing assessment and make a reasoned plan of care if
required. You should be able to:

 Assess the patient’s nursing problem accurately.

 Listen attentively to the patient’s problems and concerns
 Use clear language and question at a comfortable pace
 Clarify and check information and summarise understanding
 Be able to plan holistic safe and effective care based on your nursing assessment and best
practice.

FREQUENTLY ASKED QUESTIONS

1. When do I book my exam?

You can only begin the OSCE stage of the Overseas registration process once you have received a
decision letter from the NMC which will then enable you to contact us. The NMC will inform us of a
candidate’s eligibility to take the OSCE. We are only able to book candidates who have received this
letter.

2. What happens next?

Once the candidate enters our process they will receive a link and password to pay, following this a
link to our online booking service will be sent. The candidate chooses a date for the test which best
suits them. They will have access to all our all line resources and E-Library following payment.

3. How many test days are there?

The test centre is able to run OSCE’s 5 days a week. The University currently has the capacity to run
approximately 4000 individual tests per year. Dates available throughout the year and can be
accessed to book via our secure examination booking system.

Test date – definitions:

Open – test date is open and has availability to book

 Full – test date is fully booked

Closed – Date reserved for pre arranged trust or agency bookings

Please note, test dates are closed 14 days in advance to allow sufficient time for candidates to
prepare

4. How long does the test take?

All information is available to you in our e-learning library once you have booked and paid for your
test.

5. How much does the test cost?

The test costs £992.

6. How much will a resit cost?

A part resit will cost £496 and a full resit will cost £992.

7. Can I change my test date?

We allow rescheduling your test, but this has to happen at least 72 hours before your test date.
Should you notify us after this period your test fee will not be refunded as per the university’s
refund policy.

8. What are the documents I need to bring on the actual test date?

Two (2) forms must be downloaded in NILE: Health Questionnaire and Confidentiality Agreement.
These forms must be printed off and brought on the actual test date.

Along with these, you must bring the Original Documents you submitted online during the
application stage. These documents include the following:

 Original passport that was submitted as part of your application and the new version if this
has now expired.
 Original birth certificate
 Any change of name documents (marriage certificate, civil partnership and deed of name
change)
 Original police clearance certificates from all the countries or states that you have resided or
practised in since the age of 18
 Original diploma or degree certificate
 Registration certificates from all the countries or states that you have practiced and/or
registered with
 Original police clearance certificates that were submitted as part of your application

NOTE: We will not accept photocopies of any of the documents listed below.
ASSESSMENT
ASSESSMENT

Assessment is a systematic, deliberate and interactive process that underpins every aspect of nursing
care. It is the process by which the nurse and patient together identify needs and concerns. It is seen as
the cornerstone of individualized care, a way in which the uniqueness of each patient can be recognized
and considered in the care process.

Principles of assessment

1. It is patient focused, being governed by the notion of an individual’s actual, potential and
perceived needs
2. It provides baseline information on which to plan the interventions and outcomes of care to be
achieved
3. It facilities evaluation of care given and is a dimension of care that influences outcome and
potential survival
4. It is a dynamic process that starts when problems or symptoms develop, which continues
throughout the care process, accommodating continual changes in the patient’s condition and
circumstances.
5. It is essentially an interactive process in which the patient actively participates
6. Optimal functioning, quality of life and the promotion of independence should be primary
concerns
7. The process includes observation, data collection, clinical judgment and validation of perceptions
8. Data used for assessment process are collected from several sources by variety of methods,
depending on the healthcare setting

Types of patient assessment

1. Mini assessment – a snapshot view of the based on a quick visual and physical assessment.
Consider patient’s ABC (airway, breathing and circulation), the assess mental status, overall
appearance, level of consciousness and vital signs before focusing on the patient’s main
problem.
2. Comprehensive assessment – an in-depth assessment of the patient’s health status, physical
examination, risk factors, psychological and social aspects of the patient’s health that usually
takes place on admission or transfer to a hospital or healthcare agency. It will take into account
the patient’s previous health status prior to admission.
3. Focused assessment – an assessment of a specific condition, problem, identified risks or
assessment of care, for example, continence assessment, nutritional assessment, neurological
assessment, following a head injury, assessment for day care, outpatient consultation for a
specific condition.
 4. Ongoing assessment – continuous assessment of the patient’s health status accompanied by
monitoring and observation of specific problems identified in s mini, comprehensive or focused
assessment.

Structure of assessment

 The structure of assessment should take into consideration the specialty and care setting and
also the purpose of the assessment
 When caring for individuals with cancer, assessment should be carried out at key points during
the cancer pathway and dimensions of assessment should include background information and
assessment preferences, physical needs, social and occupational needs, psychological well-being
and spiritual well-being.
 Functional health patterns provide a comprehensive framework for assessment, which can be
adapted for use within a variety of clinical specialties and care settings.

Methods of assessment

 It should elicit both subjective and objective assessment data.

 An assessment interview must be well structured and progress logically in order to facilitate the
nurse’s thinking and to make the patient feel comfortable in telling their story.
 Specific assessment tools should be used, where appropriate, to enable nurses to monitor
particular aspects of care, such as symptom management (pain, fatigue), over time. This will
help to evaluate the effectiveness of nursing interventions whilst often providing an opportunity
for patients to become more involved in their care.
 ASSESSMENT PROCEDURE

Done after reading the chart and scenario:

1. Declare environment is safe. Check floor and under the bed for cable wires, water spillages and
any other obstacles that may cause slips and trips.
2. Perform hand washing. (Verbalized step by step)
3. Introduce yourself.
4. How do you want me to call you?
5. Confirms patient’s identity. Check wrist band for name, Date of Birth and hospital number. Ask
for any allergies.
OSCE TIP: Always remember IAL (Identity, Allergy, Allergy to Latex and others) in every station
6. Do OBS (TPR BP). Check equipment if clean, safe and if maintenance check was done and
current. Ask permission to touch patient’s wrist for RR and PR check. Do not inform patient that
you are taking RR.

For subdural hematoma, include neuro OBS (GCS, papillary reaction and libs)

For falls, include neuro obs and falls assessment. Explain the need for possible diagnostic
procedures like CT scan as standard protocol for fall patients. Assess need for referral to PT/OT
 RN to decide if increase frequency of
monitoring and/or escalation of
clinical care is required

RN to urgently inform the medical

team caring for the patient

Urgent assessment by a clinician with

5 or more or 3 in one Increase frequency to
core competencies to assess acutely ill
parameter minimum of 1 hourly
pstients

Clinical care in an environment with

monitoring facilities

RN to immediately inform the medical

team caring for the patient at least at
Specialist register level

Emergency assessment by a clinical

Continuous monitoring of
7 or more team with critical care competencies
vital signs
which includes a practitioner with
advanced airway skills

Consider transfer to Clinical care to a

level 2 or 3 facility (e.g.HDU or ITU)

Coma Scale

RESPONSE
6 Obeys command
5 localizes pain
4 normal flexion
Best Motor Response 3 abnormal flexion
2 extension
1 none
NT not testable
 Verbal Response 5 oriented
4 confused
3 words (inappropriate)
2 sound (incomprehensible)

1 none
NT not testable

T-ET tube or TT
4 spontaneous
3 to sound
2 to pain
Eye opening 1 none
NT not testable

C - eyes closed by swelling

Limb movement

RESPONSE
Normal power
Mild weakness
Severe weakness
Legs
Spastic flexion
Extension
No response
Normal power
Mild weakness
Arms Severe weakness
Extension
No response
NOTE: Record Right and Left separately if there is a difference between the two sides.

For asthma, peak flow. Ask if the patient has used the equipment before. If yes, ask her if he could
demonstrate how to use it properly. And note areas for improvement on its use.
Measuring peak expiratory flow

a. Explain the procedure to the patient. The patient can sit while performing the test
b. Demonstrate the procedure
c. Establish best or predicted PEF ideally within 2 years
d. Wash your hands (can be with an alcohol based hand rub)
e. Assemble equipment. Make sure the pointer on the meter is set at the starting position of
the scale
f. Position patient sitting upright ideally in a chair with arms and without wheels during peak
expiratory flow test as it could cause dizziness.
g. Patient must take a deep breath to full inspiration and seal the mouthpiece with his lips
and teeth around the mouthpiece.
h. Ask the patient to hold the mouthpiece horizontally to keep his fingers clear of the sliding
pointer and ask to keep his tongue clear of the mouthpiece to prevent blocking the airflow
i. Ask him breathe out as hard and fast as possible like a short, sharp huff not longer than
half a second each short breath. (Peak flow is reached within about a tenth of a second.
j. Ask the patient not to spit air into the meter as this artificially raises the reading
k. Make a note of the reading and return the sliding pointer back to the starting position.
l. Repeat 2 more times and note the readings. If the 2 best reading are more than 40L/min
apart, ask the patient to perform further blows.
m. After giving bronchodilator, you will need to wait before taking another PEF reading. Time
will vary depending on the drug used.
n. Dispose the mouthpiece according to local policy.
o. Wash hands
p. Document highest of the three readings
q. Report any concerns to manager or senior staff member
r. Ensure that the person responsible for the patient’s care is aware of the readings to decide
if any alterations to treatment or management are required.
 7. Assess reason of hospitalization
Assess presence of pain or any discomfort. Ask if he wanted to attend to it first before continuing
with the assessment. (Giving of pain medications) NOTE: Check last dose meds given at MAR
chart.
PQRST of pain (Precipitating factors / Palliation/Provocation, Quality/Quantity, Radiation,
Seveity, Timing)
Ask are you taking any medications right now? What sort of drugs?

To provide optimal patient care, the assessor needs to have appropriate knowledge of the
patient’s pain and an ability to identify the pain type and location. Assessment of a patient’s
experience of pain is a crucial component in providing effective pain management. It is
unacceptable for patients to experience unmanaged pain or for nurses to have inadequate
knowledge about pain. Pain should be measured using an assessment tool that identifies the
quantity and/or quality of one or more of the dimensions of the patient’s experience of pain.

Questions to ask related to pain:

 Are you pain free at rest and/or on movement?

 Is the pain a primary complaint or a secondary complaint associated with another condition?
 What is the location of the pain and does it radiate?
 When did it begin and what circumstances are associated with it?
 How intense is the pain, at rest and on movement?
 What makes the pain worse and what helps to relieve it?
 How long does the pain last, for example, continuous, intermittent, for stomach conditions, with
meals, before or after meals?
 Ask the patient to describe the character of pain using quality or sensory descriptions (sharp,
throbbing, burning)

8. Assess the 12 areas for ADL. (Focus on the 6 areas mentioned in the OSCE exam)

a. Maintaining Safe Environment

During this part of the assessment the nurse will assess the patient’s ability to comprehend the
present environment without showing levels of distress. This will help to establish whether
there are any barriers to the patient understanding their condition and treatment. It may help
them to be in a position to give informed consent.

Questions to ask:

 Do you know where you are?

Introduce the facility: hospital, Ward, location of toilet, use of call bell
 Do you know what the date and time is?
If no, orient to date and time
 Have you had any falls before?
If yes, reason of falls (dizziness, problems with gait and balance)
What he is doing when he fell?
 Did he lost his consciousness or had an injury from the fall (hip fracture, bruises, concussions)
 Assess if the patient is able and ready to understand any information about their
forthcoming treatment and care and any barriers to learning
 Assess if able to communicate understanding of their condition, plan of care, and potential
outcomes or responses
 Assess if able to give informed consent

b. Communication

The nurse needs to assess the level of sensory functioning with or without aids or support such as
hearing aids, speech aids, glasses or contact lenses, and the patient’s capacity to use and maintain
aids or support correctly. Furthermore, it is important to assess whether there are or might be any
potential language or cultural barriers during this part of the assessment. Knowing what the norm
within the culture will facilitate understanding and lessen miscommunication problems.

Assessment focused on:

 Ability to comprehend and use information

 The sensory functions and neurological functions

Questions to ask:

 How good is your hearing and eyesight?

 Do you wear glasses?
If you see glasses or contact lenses, ask if it’s used all the time or for reading purposes only. Ask if
he wants to use it now.
 Do have any hearing aids?
 Do you have any hearing problems?
 Previous surgeries or procedures concerning eyes and ears.
 Assess if the patient is able to express their views and wishes using appropriate verbal and
nonverbal methods of communication in a manner that is understandable by most people
 Assess if there are any potential language or cultural barriers to communicating with the patient
and provide options to facilitate or bridge such barrier or gap
 Assess need for interpreter

c. Breathing

Respiratory pattern monitoring addresses the patient’s breathing pattern, rate and depth. It is
important to assess and monitor smoking habits. It is helpful to document the smoking habit in the
format of pack years. A pack year is a term used to describe the number of cigarettes a person has
smoked over time. One pack-year is defined as 20 manufacturing cigarettes (one pack) smoked per
day for 1 year. At this point in the assessment, it would be a good opportunity, if appropriate, to
discuss smoking cessation.
 Questions to ask:

 Are you normally short of breath?

 Note if there is any noise when they are breathing such as wheezing? If stethoscope is available
in the testing room, assess and auscultate breath sounds
 Does breathing cause you pain?
 Assess how deep or shallow their breathing
 Check if breathing is symmetrical
 Has your shortness of breath become worse in the past week?
 Do you experience any other symptoms when you are short of breath?
 Have your tried smoking?
 Any other environmental factors that could trigger your respiratory condition (asthma)
 Does the patient have any underlying respiratory problems such as COPD, emphysema, TB,
asthma, bronchitis, or any other airway disease?
 For persistent shortness of breath, explain the need to be referred to respiratory specialist

d. Eating and drinking

As part of the nutrition assessment, the nurse should obtain an oral health history that includes oral
hygiene beliefs, practices and current state of oral health. During this assessment it is important to be
aware of treatments and medications that affect the oral health of the patient.

Also, an in-depth assessment of hydration and nutritional status will provide the information needed
for nursing interventions aimed at maximizing wellness and identifying problems for treatment. The
assessment should ascertain whether the patient has any difficulty eating or drinking. During the
assessment the nurse should observe signs of dehydration, for example dry mouth, dry skin, thirst or
whether the patient shows any signs of altered mental state.

Moreover, a detailed diet history provides insight into a patient’s baseline nutritional status.
Assessment includes questions regarding chewing or swallowing problems, avoidance of eating
related to abdominal pain, changes in appetite, taste or intake, as well as use of a special diet or
nutritional supplements. A review of past medical history should identify any conditions and highlight
increased metabolic needs, altered gastrointestinal function and the patient’s capacity to absorb
nutrients.

Areas to focus on:

 The pattern of food and fluid consumption relative to metabolic need

 Actual or potential problems related to fluid balance, tissue integrity

Questions to ask:

 Are you able to drink adequately? If not, explain why not.

 How much and what do you often drink?
 Have you experienced any decline in your appetite recently?
If yes, how much on average have you been eating a day?
What do you think may trigger this decline?
 Do you feel nauseous if you try taking in food? Fluids?
 How much would you normally eat?
 Are you able to swallow or chew the food? (dysphagia)
 Is there anything you don’t or can’t eat?
 Have you experienced any taste changes? If yes, ask any new medications taken
 Have you been managing to drink fluids?
 Have you lost any weight recently?
 Do you drink any alcohol?
If yes, how often and how much?
Ask for any medications he might be taking now to see if it can be affected by alcohol intake
Note the patient’s alcohol intake in the format of units per week and the caffeine intake
measured in the amount of cups per day.
 Do you wear dentures?
Does it perfectly fit you or it needs adjustment?
 Do you have any missing teeth or loose teeth ( important for risk of aspiration)
 Explain to patient that we would need to obtain his height and weight.
 Inform patient that he will be put on red tray (for patients who require assistance in feeding or
eating)
 If there is difficulty in swallowing or decrease in food and fluid intake, inform the patient of the
need to inform the doctor for nutritional review and proper management be done.

Nausea and vomiting

In this part you want to ascertain the patient has any history of nausea and/or vomiting. Nausea
and vomiting can cause dehydration, electrolyte imbalance and nutritional deficiencies and it
can also affect a patient’s psychosocial well-being. They may become withdrawn, isolated and
unable to perform their usual activities of daily living.

Questions to ask:

 Do you feel nauseous?

 If already vomited, assess the frequency, volume, content and timing
 Does nausea precede vomiting?
 Does vomiting relieve nausea?
 When did the symptoms start? Did they coincide with changes in therapy including dose,
frequency, duration, effect, route of administration?

What is the condition of the patient’s oral cavity?

e. Elimination

It is important to determine a baseline with regard to independence. It is focused on the patient’s

baseline observations with regard to continence or incontinence. Note also whether there is any
penile or vaginal discharge or bleeding. Does the patient have urinary catheter in situ? If so, list type
and size. Note the date catheter was inserted and/or removed.

Also, a detailed assessment of a patient’s skin may provide clues to diagnosis, management and
nursing care of the existing problem. A careful skin assessment can alert the nurse to cutaneous
problems as well as systematic diseases. In addition, a great deal can be observed in a person’s face
which may give insight to his or her state of mind.

Areas to focus on:

 Excretory patterns (bowel, bladder, skin)

 Excretory problems such as incontinence, constipation, diarrhea, and urinary retention may be
identified

Questions to ask:

 Can you be able to attend to your elimination needs independently?

 Are you continent? Able to hold urine or bowel?
 How often do you normally have your bowels open?
 When was the last time?
If exceeded 3 days and is unusual (or any other unusual change in pattern of BM), ask if he would
like you to inform the doctor about it so it could be dealt with accordingly
Ask what was done to initiate bowel movement? (eating fibrous diet, increase water intake)
 Was there any difference with the bowel movement the last time? Was there any mucous, loose
stool, constipation or presence of blood?
 Do you have any problems passing urine?
 Any discoloration, blood and unusual smell noted in your urine?
 Are you usually independent in going to the toilet?
 Explain that as part of the admission process, it is expected to collect urine sample as specimen.
Give reassurance that it is a routine procedure
 Does the patient have any underlying medical conditions such as Crohn’s disease or irritable
bowel syndrome?
 Does the patient have diarrhea or is he prone to or have constipation?
 How often does the patient need to urinate (frequency)
 How immediate is the need to urinate? (urgency) to access ability to hold urine
 Do you wake up at night to urinate? (Nocturia) common for DM patients
 Do you have any wounds or sore places in the skin?
 Do your wounds heal normally or slower than usual?
 Assess for any dryness, redness, or swelling of the skin, also for any presence of pressure sores
 Grades of Pressure Ulcers
1 - non-blanchable erythema of intact skin
2- presents clinically as an abrasion or blister
3- superficial lesions
4- deep lesions, extensive destruction, tissue necrosis or damage to muscle, bone and
supporting stuctures

Pressure Ulcer Assessment Tools

Norton Scale

Patients with a score of 14 or below are considered to be at greatest risk of pressure ulcer
development. A score of 14-18 is not considered at risk but will require reassessment and a
score of 18-20 indicates minimal risk. The cut –off point of at risk patients was later raised to 15
or 16 by Norton.

Physical Mental
Score Score Activity Score Mobility Score Incontinent Score
Condition Condition
Good 4 Alert 4 Ambulant 4 Full 4 Not 4
Slightly
Fair 3 Apathetic 3 Walk help 3 limited 3 Occasionally 3
Very Usually or
Poor 2 Confused 2 Chairbound 2 limited 2 urine 2
Very Bad 1 Stuporous 1 Bedfast 1 Immobile 1 Doubly 1

Waterlow Scale

It defines a score of 11-15 as being at risk, 16-20 as high risk and over 20 as very high risk.
 Braden Scale

It is based on six subscores which are scored from 1 to 4 depending on the severity of the
condition with the exception of friction and shearing which is scored only up to 3. The total
score is then added up with a possible range of 6 to 23. The lower the score, the higher the risk
of developing a pressure ulcer. Hospital patients are at risk if their score is 16 or below.

1 2 3 4
Completely
Sensory perception limited Very limited Slightly limited No impairment
moisture Constantly Very moist Occasionally Rarely moist
moist moist
activity Bedfast Very limited Slightly limited No impairment
Completely
mobility immobile Very moist Occasionally Rarely moist
Probably
nutrition Very poor inadequate adequate Excellent
No apparent
Friction and shear Problem Potential problem problem

f. Washing and dressing

The nurse should also evaluate the patient’s ability to meet personal hygiene, including oral hygiene
needs. This should include the patient’s ability to make arrangements to preserve standards of
hygiene and the ability to dress appropriately for climate, environment and their own standards of
self-identity.

 Do you usually wash and dress yourself? Do you do it at daytime or night time?
Do you prefer warm or cold water for your wash?
 Would you prefer a male or female nurse to assist you with personal hygiene if required?
 Inform that if assistance is required, using the call bell would help
 Assess degree or level of assistance required (doing up buttons, brushing hair)
g. Controlling body temperature

It is carried out to establish baseline temperature and determine if the temperature is within normal
range, and whether there might be intrinsic or extrinsic factors for altered body temperature. It is
important to note whether any changes in temperature are in response to specific therapies
(antipyretic medications, immunosuppressive therapies, invasive procedures or infection)

Questions to ask:

 Are you warm enough in this room?

 Do you feel the cold easily?
 If having fever, ask if antipyretic or any other medication has been taken to address it, check the
MAR as well.
 Ask if what other measures are being done to reduce temp

h. Mobilisation

It aim is to establish the level of assistance required by the person to tackle activities of daily living
such as walking and steps/ stairs. An awareness of obstacles to safe mobility and dangers to personal
safety is an important factor and part of the assessment.

Areas to focus on:

 The ADLs requiring energy expenditure, including self-care activities, exercise and leisure
activities
 The status of major body systems involved with activity and exercise is evaluated, including the
respiratory, cardiovascular, and musculoskeletal systems

Questions to ask:

 Are you able to walk around independently?

 Are you able to move up and down, roll and turn in bed?
 Do you use a cane, frame, walker or any assistive devices?
 How far can you usually walk?
 Do you experience any shaking or unsteady gaits while walking?
 Do you experience difficulty initiating a walk or when stopping?
 Do you drive?
 Assess what type of assistance do they need: help with mobility or fine motor movements such
as doing up buttons or shaving
 Fall assessment tool
Do you feel steady on your feet?
If needs assistance, ask if the patient would mind to be referred to an OT or PT
Gives health education on importance of using the call bell for assistance
Assess for any contractures or fractures that could affect mobility
i. Working and playing

 What would you like to do on your spare time?

 Have you been able to do these activities recently?
 Discuss if he would like to call his family if he would like to bring some of his belongings
 Discuss resources available in the hospitals and how to access this ( radio, television)
 Volunteer to bring books or journals from the library


j. Expressing sexuality

Understanding sexuality as the patient’s perceptions of their own body image, family roles, and
functions, relationships and sexual function can help the assessor to improve assessment and diagnosis
of actual or potential alterations in sexual behavior and activity.

Assessment in this area is vital and should include relevant feelings about the patient’s own body, their
need for touch, interests in sexual activity, how they communicate their sexual needs to a partner, if
they have one, and the ability to engage in satisfying sexual activities.

This may also be an opportunity to explore with the patient’s issues related to future reproduction if this
is relevant to admission.

Area to focus on:

 The person’s satisfaction and dissatisfaction with sexuality patterns and reproductive functions
 Concerns with sexuality may be identified

Questions to ask:

 Are you currently in a relationship?

 How long have you been married?
 Is your wife fit and well?
 Do you have any children?
 Has your condition had an impact on the way you and your partner feel about each other?
 Has your condition had an impact on the physical expression of your feelings?
 Has your treatment or current problem had any effect on your interest in being intimate with
your partner?

k. Sleeping

It is carried out to obtain sleep and rest patterns and reasons for variation. Description of sleep patterns,
routines, and interventions applied to achieve a comfortable sleep should be documented. The nurse
should also include the presence of emotional and/or physical problems that may interfere with sleep.
Questions to ask:

 What is your normal sleeping pattern?

 How many pillows do you need to sleep with?
 Do you have any shortness of breath or any problems in breathing when asleep of when
lying down? Like sleep apnea, snoring sleep walking, orthopnea
 Do you sleep with the lights on or off?
 What is your bedtime routine? Like having a hot bath, drink a glass of milk, cup of tea
 Do you take any night sedation? Remind that sleeping pills, antihistamines and other
sedatives should not be taken with alcohol.
 Do you have enough energy for desired ADLs?
 Do you tire easily?
 Do you have any difficulty falling asleep or staying asleep?
 Do you feel rested after sleep?
 Do you sleep during the day?
 What are your normal hours for going to bed and waking?

l. Death and dying

Questions to ask:

 Do you follow any religion?

Consider Advance directives, DNACPR, UFTO, spiritual and religious beliefs

9. Inform that the initial assessment is done. Emphasize that ongoing assessment is necessary
during the entire hospital stay.
10. Give the call bell. Instruct how and when best to use it. Showing and trying how it is activated
may be essential.
11. Ask if he wants the side rails be up.
12. Ensure patient is safe, comfortable in his position, bed at lowest position, can reach the table
or assistive devices.

NOTE: Perform handwashing or hand rub accordingly every before and after patient contact.

OSCE TIPS:

 For pre and post op patients who wish to drink water, check chart if still on Nil by Mouth status.
If not, inform the patient that you will still need to verify with his doctor if he will be allowed to
take fluids or food.
  For asthma patients, check the side table for any cigarette sticks or lighter. Health teaching of
No smoking within the hospital premises especially in the room where there is piped-in oxygen
is a must. You can confiscate these and inform the patient that you will give it to his relatives
BUT ASK PERMISSION AND EXPLAIN IN THE NICEST AND MOST PROFESSIONAL WAY POSSIBLE.
 For patients who are in pain and is requesting for a pain medication, if you are unsure when the
last dose was given, inform the patient that you will still need to verify the time the medication
was last given. Usually, pain medications given orally kicks in 30 minutes to an hour, if the time
the med was given has not pass this time yet, inform the patient to wait for some time to allow
the drug to fully take effect.
 If glasses or spectacles or hearing aids are found on the side table, ask the patient if he wishes to
use them during the assessment.

Nutrition Screening in Adults

AIM

To quickly identify patients who may be at risk of malnutrition. As all patients are potentially at risk of
disease-related malnutrition, all patients should be screened when first admitted to hospital and at
regular intervals thereafter.

Malnutrition Universal Screening Tool (MUST)

It is a valid and reproducible tool that can be used in all adult-care settings in both primary and
secondary care. It has five steps:

1. Measure height and weight and calculate BMI score

 If height could not be measured:

o Use recently documented or self-reported height (if reliable and realistic)
o If the subject does not know or is unable to report his or her height, use one of
the alternative measurements to estimate height (ulnar length, knee height or
demispan)
o Estimating height from ulnar length:
 Measure between the point of the elbow (olecranon process) and the
midpoint of the prominent bone of the wrist (styloid process)

 If height and weight cannot be obtained:

o Use mid-upper arm circumference (MUAC) measurement to estimate BMI
category
o Estimating BMI from MUAC:
 Left arm should be bent at the elbow at 90 degree angle, with the upper
arm held parallel to the side of the body. Measure the distance between
the bony protrusion on the shoulder (acromion) and the point of elbow
(olecranon process). Mark the midpoint. Ask the subject to let the arm
 hang loose. Measure around the upper arm at the marked point,
making sure the tape measure is snug but not tight.
 If MUAC is <23.5 cm, BMI is likely to be <20kg/m2
 If MUAC is >32.0 cm, BMI is likely to be >30kg/m2

 If height, weight or BMI cannot be obtained

o The following criteria, which related to them, can assist your professional
judgement of the subject’s nutritional risk:
 BMI – thin, acceptable weight, overweight, obvious wasting (very thin),
and obesity (very overweight) can also be noted#
 Unplanned weight loss – clothes and/or jewelry have become loose
fitting (weight loss); history of decreased food intake, reduced appetite
or swallowing problems over 3-6 months; presence of underlying
disease or psychosocial or physical disabilities likely to cause weight
loss.
 Acute disease effect – no nutritional intake or no likelihood of any
intake for more than 5 days

2. Note the recent percentage weight loss and score using the MUST table. If recent weight loss
cannot be calculated, use self-reported weight loss (if reliable and realistic). Another useful way
to monitor weight change in someone who cannot be easily weighed is to use the percentage
change in mid-upper arm circumference (see below); this will be similar to the percentage
weight change in weight or BMI over the same period of time.

3. Establish the acute disease effect score

4. Add the scores from steps 1, 2 and 3 together to obtain an overall risk of malnutrition

5. Use management guidelines and/or local policy to develop a care plan

BMI Score Weight loss score Acute disease effect score

0 - >20 (>30 obese) kg/m2 0 - <5% 2 – If the patient is acutely ill and
1 – 18.5-20 1 – 5-10% there has been or is likely to be
2 - <18.5 2 - >10% no nutritional intake for >5 days
Management guidelines (Step 5)

Low risk (0): Routine clinical care Repeat screening:

 Hospital – weekly
 Care homes – monthly
 Community – annually for special groups (e.g.
those >75 y/o)
Medium risk (1): Observe  Document dietary intake for 3 days if the
patient is in hospital or a care home
 If improved or adequate intake – little clinical
concern; if no improvement – clinical concern
– follow local policy

Repeat screening:
 Hospital – weekly
 Care homes – at least monthly
 Community – at least every 2 to 3 months
High risk (2 or more): Treat  Refer to dietitian, nutrition support team or
implement local policy
 Improve and increase overall nutritional intake
 Monitor and review care plan
 Hospital – weekly
 Care homes – monthly
 Community – monthly
All risk categories  Treat underlying condition and provide help
and advice on food choices, eating and
drinking when necessary
 Record malnutrition risk category
 Record need for special diets and follow local
policy
Obesity  Record presence of obesity. For those with
underlying conditions, these are generally
controlled before the treatment of obesity.
 Neurological Observations

Assessing consciousness

 Consciousness cannot be measured directly. It can only be assessed by observing a person’s

behaviour in response to different stimuli.
 The response the patient gives indicates the level at which the sensory information has been
translated within the central nervous system

Neurological observation includes:

 Assessment of conscious level

 Limb assessments
 Pupil size and reaction to light
 Vital signs

Glasgow Coma Scale

 It is universally used to assess conscious level in the acute phase of brain injury and should
be charted as a graph to enable easy identification of a change in the patient’s condition. It
is more accurate in assessing altered levels of consciousness due to cerebral trauma than
medical causes of coma.

Eye opening

It looks at the arousal mechanisms and control of the eyes in the brainstem. Even when the brain
damage is severe, all patients who survive will eventually open their eyes (usually 2 to 4 weeks).
Spontaneous eye opening merely indicates that the arousal mechanisms in the brain stem are active but
does not necessarily mean that the patient is aware.

SCORE DESCRIPTION CRITERION

4 Spontaneous Observed before you approach the patient or speak
to him or her
3 Eyes open to sound After spoken or shouted request (e.g. call the
patient’s name)
2 Eyes open in response to Apply pressure to the fingertip using a pen or a pencil.
pressure Apply pressure with increasing intensity (up to 10
seconds) until you have applied the maximum
stimulus, used in order to minimize the potential
harm.

NOTE: Do not apply a central stimulus to the

supraorbital nerve when assessing eye opening, as
this will cause grimacing and eye closure.
1 None No eye opening at any time, in the absence of any
interfering factor. Ensure that the pressure stimulus is
adequate.
NT Not testable If the patient’s eyes are closed due to a local factor
such as swelling.
Verbal response

It assesses 2 elements or cerebral functioning: comprehension and transmission of sensory input and
the ability to articulate a reply. An oriented response shows a high degree of integration within the
nervous system. Patient with an ET tube or Tracheostomy tube may be able to communicate by a means
other than voice to indicate that he or she id orientated (e.g. by mouthing words or by writing) and
should be documented as such.

SCORE DESCRIPTION CRITERION

5 Orientated The patient should know who he is, where he is, and
the month. If the patient answers one or more
component wrongly then record him as confused.
4 Confused Not orientated but the patient’s communication is
coherent
3 Words Utters occasional words rather than sentences.
2 Sounds Only moans or groans
1 None No audible response, in the absence of any interfering
factor
NT Not testable Factors that interfere with communication (ET tube or
trach tube)

Motor response

In patients who have suffered traumatic brain injury, this test is the most important prognostic aspect of
the GCS. The record of the patient’s best response indicates the functional state of the brain as a whole.
You should record only responses of the upper limbs, as these are more reliable that lower limb
responses, which could be due to spinal reflexes.

SCORE DESCRIPTION CRITERION

6 Obeying commands The patient successfully performs a 2-step action such
as grasping and release of hand, open mouth and
stick-out tongue.

If the patient does not obey commands, peripheral

stimulus alone is inadequate to assess the motor
component, and an additional central stimulus is
needed.

1. Trapezius pinch – Place hand over patient’s

shoulder and press fingers into the muscles of
the shoulder blade. Apply pressure with
increasing intensity (up to 10 seconds) until
you are sure that the response you observe is
the best response.
2. Supraorbital notch – Apply pressure to
supraorbital notch. Place hand on the
patient’s forehead with the thumb over the
 upper rim of the orbit. Feel for the notch in
the supraorbital margin. Apply pressure with
increasing intensity (up to 10 seconds) until
you observe best response. Do not rate the
patient as having an absence of stimuli until
you have applied the maximum stimulus.
5 Localizing If the patient responds by bringing the hand above
the clavicle in an attempt to move the stimulus away.
If the upper limb does not reach the clavicle but does
flex, then the patient is flexing either normally or
abnormally. In clinical practice, the assessment of
these non-localising responses is based on a
combination of both peripheral and central stimuli.
4 Normal flexion The elbow bends and the arm moves rapidly away
from the body and away from the stimulus
3 Abnormal flexion The elbow bends slowly and the arm comes across
the body (abnormal flexion may be accompanied by a
spastic flexion)
2 Extension The patient extends the arm (straightens the elbow)
1 None No movement in arms or legs, in the absence of any
limiting factors. You must ensure that the stimulus is
adequate.
NT Not testable If the patient is paralysed or there are other limiting
factors

Pupillary response

 It is dependent upon intact afferent (optic nerve) and efferent (oculomotor nerve) function
transmitting the light impulse from the retina to the midbrain to papillaru musculature
 Dilating pupil indicates expanding lesion on the same side
 Bilaterally fixed and dilated pupils in patient whose motor response is flexion or localizing
suggests the recent occurrence of a seizure
 Pupil abnormalities are late signs of intracranial complications, and require ICP monitoring
 Damage to the cervical cord or brachial plexus can cause inequality of the pupils

Assessing direct light exposure

 Move a bright pen-torch from the outer aspect of the eye towards the pupil. The pupil
should constrict briskly.
 Remove the light source. The pupil should dilate to its original size. This constriction and
dilation is the direct light response. Repeat for the other eye.

Limb responses

A difference in responsiveness in one limb, compared to the other, indicates focal brain damage.
Hemiparesis or hemiplegia usually occurs in the limbs of the opposite side to the lesion. However, they
may also affect the limbs on the same side of the lesion due to pressure on the contralateral
hemisphere. This false localizing sing is called tentorial herniation (Kernohan’s notch) syndrome.

Assessing arm responses

 Hold one of the patient’s arms at the wrist and ask her to pull her arm towards her shoulder
against resistance (you should pull in the opposite direction)
 Then ask her to push your hand away, while you provide a force in the opposite direction. If the
patient has a weakness, she will not be able to resist your movement.

Assessing leg responses

 Ask the patient if she can raise her leg off the bed and hold it there. If she can, but the nurse can
push it back down the bed, a mild weakness is indicated. If the patient can move some muscles
within the limb but is not able to raise it against gravity, severe weakness is indicated.
 Apply a downward pressure to the patient’s ankle with your hand and ask her to raise her leg. It
should not be possible to overcome the patient’s movement.
PLANNING
 PLANNING AND DOCUMENTATION

Nursing Diagnoses

 It provides a focus for planning and implementing effective and evidence-based care.
 It consists of identifying nursing-sensitive patient outcomes and determining appropriate
interventions that will enable the individual to reach their desired outcome
 When planning care, it is vital to:
o Determine the immediate priorities and recognize whether patient problems require
nursing care of whether a referral should be made to someone else#
o Identify the anticipated outcome for the patient, noting what the patient will be able to
do and what time frame
o Determine the nursing interventions, that is, what nursing actions will prevent or
manage the patient’s problems so that the patient’s outcomes may be achieved
o Record the care plan for the patient which may be written or individualized from a
standardized or core care plan or a computerized care plan

Measurable and non-measurable verbs for use in outcome statements

The following words are helpful in wording your care plans. All interventions and evaluation must be
specific and measurable.

Measurable verbs (must be used)  State

 Verbalize
 Communicate
 List
 Describe
 Identify
 Demonstrate
 Perform
 Will lose
 Will gain
 Has an absence of
 Walk
 Stand
 Sit
Non-measurable verbs (must NOT be used)  Know
 Understand
 Think
 Feel

Essentials of Quality Care Plans or Records

 Be patient-centered
 Contain the actual work of nurses including education and psychological support
 Reflects the objective clinical judgement of the nurse
  Be logical and sequential
 Be written contemporaneously or as events occur
 Record variances in care
 Fulfill legal requirement

Members of the Multidisciplinary team and their roles

The following are information to support assessment, complete care plans for referral and transfer of
care letter at OSCE:

 Physiotherapist – suppot in mobilization and chest physiotherapy. Nurse referral can be done.
 Occupational therapist – support with assessing patients with individual needs with regards to
ADLs, including washing, dressing, eating, and kitchen assessments. They help identify
equipment to make tasks easier for patients in hospital and at home. Nurse referral can be
done.
 Speech and Language therapist – they support patients with speech and language problems
including swallowing difficulties. Nurse referral can be done.
 Discharge planning team – they help organize patient’s discharges who require car in the
community. Nurse referral can be done.
 Pain team – these are specialist nurses who specialize in acute and chronic pain management of
in- and out- patients. Nurse referral can be done.
 Falls coordinator – all patients who are admitted who have fallen or identified as being at risk
using the fall risk tool on admission are referred to falls coordinator.
 Respiratory specialist nurse – refer patients with chronic breathing problems for education and
support in hospital and the community
 Diabetes team – a team of specialist nurses who care for diabetic in- and out- patients. They
support diabetic patients who are unstable due to surgical interventions or acute/chronic
disease. Initial referral needs to be made to the Diabetic Registrar, thereafter, you can refer to
the Diabetic nurse.
 Dieticians – patients identified from the MUST tool that require intervention from the dieticians,
need to be referred by the nursing or medical team.
 Care Plan
Patient Details:
NAME
AGE
DATE OF BIRTH

Complete each section. Please write clearly.

NURSING PROBLEM/NEED/ACTIVITY OF LIVING:

AIM(S) OF CARE:

RE-EVALUATION DATE:
To be evaluated each shift or if his clinical condition changes
CARE BY NURSE(S) SELF-CARE
Explain and discuss aspects of care to (patient’s name) and (Patient’s name) and his next of kin
gain consent for all interventions verbalizes their understanding of his plan
of care
(Assessment) (at least 2 self-care actions related to
problem)
(Medication/Treatment/Interventions) Related to assessment, medication or
treatment referral
(Monitoring for effects of interventions) (Patient’s name) verbalizes that she
understands the education given
(Referral) (Patient’s name) will actively participate in
her care plan
Inform and reassure (patient’s name) of his plan of care
Promote (patient’s name)’s knowledge and understanding
of his treatment
Document all care as planned

Nurse Signature Date