Wednesday, February 08, 2012

GNIE lesson: Head-to-toe examination

Since some of my blog readers are heading to the CRNBC IEN SEC assessment (for Internationally Educated Nures, Substantially Equivalent Competency). I thought I'd share what I learnt from the GNIE program (Graduate Nurse Internationally Educated) that might be of use. Hope the following helps.

Click here to skip to a summary of the head-to-toe examination points.



[Minor updates done on 09-Feb-2012 evening, after simulation lab review.]

Patient assessment is a very important skill for RNs in BC. RNs need to assess every patient at least once every shift.

During the SEC, there is a role-play segment. You will probably need to do a "head-to-toe" examination of your patient. With some practice, it would take around 5 minutes. Add another 5 minutes for taking vital signs, it would be around 10 minutes for the basic assessment. Here's a fictitious scenario. Note: The dialogue is important as the SEC assessment is not only about your nursing skills but your ability to use English in a nursing setting.


Nurse Joy knocks on patient's door.

Patient: Please come in.

Nurse: Good morning. My name is Joy. I am the nurse taking care of you today. How would you like me to address you?

Patient Mary: Hello, Joy. You can call me Mary.

Nurse Joy: Well, Mary, could you tell me your date of birth please?

Patient Mary: 8th of February, 1980.

Nurse Joy: Could I check your ID band please?
Nurse checks the ID band to ensure that it's the right patient. If the patient's reply is right, patient is Oriented x1 (to person).
Nurse Joy: Mary, tell me, how are you feeling today?
Nurse asks question to build rapport and also note if patient has any complaints. Note: Nurse also observes the general status of the patient. E.g. Alert, drowsy, in bed, sitting on chair, skin colour, looks pale, looks flushed, etc. Also note any devices hooked to the patient. E.g. IV, oxygen, chest tube, urine catheter, etc. Any mobility aids: cane, walker, wheelchair. Any other personal stuff: reading glasses, dentures, valuables on bedside.
Patient Mary: I don't feel so good because I didn't sleep well yesterday night. I kept waking up because I have this headache that just wouldn't go away.

Nurse Joy: I see. How would you rate your pain on a scale of 0 to 10? 0 for no pain to 10 for extremely painful.

Patient Mary: Maybe about 3?

Nurse Joy: Ok. I will check your medications later to see if you have anything that may help with it. Is it alright if I do some health checks with you now?
Note: Pain is part of the vital signs. Since patient's pain level isn't extreme, we can proceed with the examination and return to it later.
Patient Mary: Oh, will it take long?

Nurse Joy: It will only take about 10 mins.

Patient Mary: Ok.
Nurse adjusts height of bed to comfortable working level, i.e. no need to bend to assess patient. Nurse Joy takes the vital signs. Note: Remember the normal range for each of these. Temperature (remember the normal range for various routes), blood pressure, heart rate (radial pulse for 15sec if possible. If pulse is regular, x4 for a 1-min count), respiration rate (observe for 15sec. If breathing is regular, x4 for a 1-min count). At each stage, the nurse should inform the patient what she/he is about to do before starting, so as to cue the patient.
Nurse: I'm going to check your temperature. Open your mouth and put this under your tongue.

Nurse: I'm going to check your blood pressure. Please lend me your arm. The cuff will tighten and then loosen against your arm, ok?

Patient nods.

Nurse: I'm going to check your pulse. Please lend me your hand.

Nurse: I'm going to check your oxygen level. I will clip this to your finger. is that ok?
Nurse clips SpO2 probe on finger, checks the SpO2, and then removes the probe.
Nurse: I'm going to check your breathing. Please breath normally.

Nurse: You mentioned earlier that you have headache. When did it start? And can you describe how it feels?

Patient: Well, it started yesterday night. It's a throbbing pain.

Nurse: What makes it worse? What helps to ease it?

Patient: It feels worse when the overhead lights are on. I don't know what may ease the pain.
Nurse notes down the qualities of pain: Location, strength, characteristic (e.g. throbbing), when it started, what worsens pain, what reliefs pain, impact on daily activities (e.g. interrupts sleep).
Nurse: Thank you for informing me. Shall I continue with the rest of the examination?

Patient: Ok.

Nurse: Do you know where you are?

Patient Mary: In the hospital.

Nurse: What's today's date?

Patient Mary: I don't know. Wednesday or Thursday? 10th of February?
Note: Neurological assessment. If patient is oriented to person, time, and place, then patient is ORIENTED X3. If not, then, it is x1 and x2 for giving 1 or 2 of 3 correct answers respectively. As for the date, give a 1-2 days allowance for error.
Nurse: I am going to shine a light to check your eyes. Look straight at me.
Nurse uses 1 hand cover the other eye (or use the hand as a divider, just above the nose, to block the light on the other eye). Then shines light in each eye.
Nurse: Ok, I'm going to listen to your heart and lung sounds. If you feel uncomfortable at any point, please let me know. Is it ok if I lift your gown for it?

Patient: Ok.

Nurse: Take deep breaths in and out.
Nurse lifts the patient's gown to auscultate for heart sounds. See here for the 4 percordial locations to auscultate. And click here for the locations to auscultate the anterior lung sounds.
Nurse: I'm going to listen to your abdomen for bowel sounds next.

Patient: What are bowel sounds?

Nurse: It's the sounds made by your abdomen as it digests food. Shall I proceed?

Patient nods.
Nurse mentally divide the abdomen into 4 quadrants using the umbilicus, a.k.a. belly button, as the landmark. Then listen to all 4 quadrants. Normally there will be bowel activity in all 4 quadrants. You will need to listen more than 5 mins before concluding that there is no bowel sound in a specific quadrant. Nurse covers the patient anterior with gown.
Nurse: Have you gone to the toilet this morning?

Patient: Nope.

Nurse: When did you last pass urine? And pass motion?

Patient: I peed and pooped yesterday night before going to bed.

Nurse: What did your stool look like?

Patient: Like lumpy toothpaste.

Nurse: Is that your normal?

Patient: Yes, I usually go once every 2 days and my stools are usually lumpy.
Nurse to note elimination information.
Nurse: I'll check your hands now. Can you squeeze both my hands?
Nurse holds each of patient's hands in his/her own hands. Instructs patient to them simultaneously. Check for strength and whether it is balanced on both sides. Then nurse check the fingers for capillary refill (should return to pink in less than 2 sec). Followed by checking the quality of radial pulse on both sides simultaneously. They should be in-synch, and equally strong and regular.
Nurse: I will need to check your breathing from the back. Please can you sit up?

Patient sits up.
Nurse to auscultate for posterior lung sounds. Nurse can adjust the head of bed upwards if patient is not strong enough to sit up on his/her own. Note: Depending on situation, sitting up may be contra-indicated for the patient, e.g. neck spinal surgery patients. Adjust your assessment accordingly.
Nurse: Thank you. You may lie down. I am going to check your feet and legs next.

Patient: Ok.
Nurse palpates for dorsal pedal pulse and posterior tibial pulse on both feet. In addition, check for capillary re-fill to the toes. This is to ensure that there is circulation both feet. Followed by pressing onto the fleshy areas above the ankles for edema pitting rating. Nurse places one hand on the dorsal side of each foot.
Nurse: Can you pull your toes to your nose against my hands?

Patient does so.
Nurse places each hand on the ventral side of each foot (i.e. the sole).
Nurse: Can you push against my hands by as if you're pressing on the brakes?

Patient does so.
Nurse places each hand on each knee.
Nurse: Can you lift up your knees against my hands?

Patient does so.
In each of the above, nurse to note the strength in each leg, and whether it is equal bilaterally.
Nurse: Ok, we are done with the assessment. Do you have any questions or requests?

Patient: Yes, I would like to order something soupy instead of normal meals today. My headache is affecting my appetite.
Nurse to note addition impact of pain on patient's activity, i.e. reduced appetite. Nurse passes the call-bell to patient, ensures that the top 2 bed-rails are up and the bed is set back to the lowest height for patient safety.
Nurse: Ok, Mary, I will change your meal order for you. If you have further questions or need any assistance, please press the call-bell for assistance. I will revert to you regarding your pain medication in a few minutes.

Patient: Ok, see you later.

Nurse exits room.


Summary of head-to-toe assessment. Here's a short list of items to check and the normal results.
  1. Self-introduction
  2. In's and Out's (to chart under each corresponding body system): E.g. Oxygen running at 2L/min on NP (nasal prong). E.g. NGT in-situ. E.g. IV in-situ, running NS at 100cc/hr (Note also redness, edema, ecchymosis, discharge of IV site). E.g. Foley (catheter) in-situ, drained approximately 300cc of clear urine. E.g. Ostomy in-situ, with small amount of liquid brown stool and flatus++. 
  3. General questions and observation (Neurological). Patient alert and oriented x3 (i.e. person, place and time), i.e. A+O x3.
  4. General questions and observation (Psychosocial). Note the patient's mood, affect and any psychosocial issues.
  5. General questions and observation (Activity). Note the patient's activity levels. E.g. ADLs (sat in chair, sat in bed, walked along corridor), mobility, sleep.
  6. Eyes (Neurological). PERL (pupils equal and reactive to light) or PERRLA if accommodation is tested (pupils equal, round, reactive to light and accommodation).
  7. Lung sounds (Respiratory): Respiration easy and regular. Clear air entry (A/E) throughout lung fields. No adventitious sounds noted. 
  8. Heart sounds (Cardiovascular). Apical pulse strong and regular, no extra sounds.
  9. Abdomen (Gastrointestinal): Abdomen soft and round, no discomfort. Bowel sounds present in all quadrants.
  10. Arms and legs (Cardiovascular): Bilateral radii pulses strong, regular and equal. Pedal pulses present bilaterally. Capillary refill < 3 sec on all extremities. Skin pink, warm and dry to touch. That is, Colour Warmth Movement and Sensation (CWMS) satisfactory on all extremities. Note edema, if any.
  11. Arms and legs (Neurological): Bilateral hand grips strong and equal. Both feet dorsiflex and plantar-flex against resistance. Bilateral knees lifted against resistance.
  12. Urine/Stool (Genitourinary): Patient up to bathroom to void independently. Last voided ..., last bowel movement ...
  13. Skin: Note any cuts, breaks, sores, etc. Size and colour. For incisions, note REEDA (Redness, Edema, Ecchymosis, Discharge, Approximation) and COCA of discharge (colour, odour, consistency, amount). Describe dressings, if any.


  1. What cow... so long process of talking.

    When i was quarantined in suspected sars isolation ward couple of years back, the nurse didn't talk so much. Though she's in protective suit i can sense her fear by looking at her eyes.

    I scare of needles after all the poking on my forearm to draw blood to test.

    My suspected case is viral fever upon further diangosis.

    1. Hi Xianlong,

      Your example refers to the ER dept in a Singapore hospital, which is not what is illustrated above.

      The above is a scenario of patient assessment in a Canadian hospital ward. Yes, it is somewhat "textbook" like as the intended audience is the IEN SEC applicants. They need to follow this "textbook" approach in order to pass the assessment for a shorter route towards getting their RN qualifications in B.C., Canada.

      Anyway, in Canada the RN-to-patient ratio is much lower than in Singapore. In a typical acute ward, an RN & a LPN (EN in Singapore-speak) share the care of maximum 8 patients/shift, so typically each gets 4 patients. The LPN functions independently. The doctors rely on the nurses assessments, and don't need RNs to be their hand-maiden (more equal relationship). There is a Health-Unit Coordinator who transcribes the doctors' orders and arranges for the labs/tests/transfers. In addition, there is a Patient Care Co-ordinator who takes care of next-of-kin and other communication matters. All this additional support is provided so that RNs & LPNs can focus on nursing. The workload factor alone is enough to tempt nurses in Singapore to leave for greener pastures. Don't need to talk about the pay difference, right from the starting pay.

      In Singapore, my RN experience involves caring for 12 patients/shift (worst case scenario 14 patients simultaneously). Sometimes we have an EN to assist us. Sometimes we have to share that EN with another RN. Sometimes we don't even have an EN but a HCA (who cannot handle medication or do any procedures). Sometimes, we even have to share that HCA. Depending on one's luck, sometimes we get a skiving EN who "cannot do this" & "cannot do that" and behaves like an HCA (health care attendant). You can read my "Nursing in Singapore" blog entries to see what other BS we have to attend to besides actual nursing. I calculated that each patient is really lucky if he/she gets 30 mins of my time each 7.5 hour shift. Of course, no need to say, what that does to the quality of nursing care one gets in Singapore.

      I'm glad that I'm out of that system.

  2. hi! i love reading your blog, very informative. i am also an IEN and will soon take SEC and needed to read more about the assessment. could i ask you to post more of your GNIE notes that might come in handy on that part of the exam that is sort of a return demo type (sorry couldn't recall at the moments what it's called) like wound dressing, IV ....
    hope to read more of your post. thank you.


    1. Hi Marian,

      Thanks for visiting and your feedback. For my GNIE related notes, you can try clicking on the "Nursing in Canada" quicklink on the top-right keywords bubble, or entering "GNIE" in the top-left search field.

      Here are a few that, IMHO, may be useful to understand the Canadian nursing norms and values.

      GNIE: Bevel Up

      GNIE: Anecdotal notes = Get out of jail, free pass

      GNIE: Clinical anecdotal notes

      IEN preparing to apply to CRNBC

      CRNBC IEN SEC assessment possible outcomes

      Good luck for your SEC. If you don't mind, please return to drop a note/comment on the "IEN preparing to apply to CRNBC" blog entry to share your experience with others. I believe there may be other IENs who are interested in the challenges faced. Just be careful not to leak any assessment specific contents when you share, ok? (So that you will not breech the confidentiality of the assessment.) Thanks!

      Cheers, WD.

  3. Hi WD!
    Visited your blog before, I'm back again as my SEC assessment is next week the 5th & 6th of Nov.
    Just want to ask a bit more about the OSCE (role-play).
    As I understand, you are given a card to try and complete the task like say, collect history from patient or perform a head to toe assessment.
    I would like to ask, does each card (scenario) have a time limit (ie.10 mins to collect history or 15 mins to complete head to toe assessment)?
    And also when you write down notes (ie. collecting history) is it on blank piece of paper or is there a pre-printed format you follow?
    Sorry for the questions. I know it's been a while since you did your SEC but I would greatly appreciate it if you could share a bit more info for me.
    Take care and congrats on passing the CRNE!


    1. Hi Ryan,

      Thanks for visiting and sharing your questions. Actually, IMHO, you've asked good questions. Since you're not asking about the OSCE contents itself, I guess it is ok to answer your questions. As you've noted, my SEC was years ago (early-2011), so things might have changed since then -- Disclaimer: Do not take what my commentary as advice but just a sharing of experience, I do not guarantee the accuracy, completeness, or usefulness of any information provided by me.

      > does each card (scenario) have a time limit...?

      No, but the assessor may instruct you to stop your tasks anytime and moves on to the next question/step.

      > And also when you write down notes (ie. collecting history) is it on blank piece of paper or is there a pre-printed format you follow?

      Oops, sorry, I don't remember writing down notes. If I recall correctly, there was a piece of paper given to me for calculations for medication admin, but that's it. Basically, for each follow-up question on the scenario, the assessor gave me a card with the relevant information on it, and if you need any additional information, you can ask the assessor for it.

      Good luck on your SEC. Hope you'll come back to this blog and share about your experience (just don't give the details of the contents away).

      Cheers, WD.

  4. Hey WD!
    I really appreciate your swift reply. I'm just a few days away from my SEC. Knowing a bit more info about it surely helps a lot.
    I'm aware of the confidentiality of the SEC, hence the reason I only ask about the time limit and taking notes.
    I will surely come back here once it's over.
    Your blog has been really helpful to me and I'm certain to many others.
    I even found out on your blog about the 250hrs that I don't need to do it anymore (well, once I pass the SEC).
    Please keep up your good work.
    Very big thanks to you!