Physical assessment rubric with instructor Flashcards
how many major categories for assessment are there?
10
What are the major categories and how many are there?
Miscellaneous
Neurological
Cardiovascular
Respiratory
Hemodynamics
Gastrointestinal
Genitourinary
Wounds/Incisions if applicable
Vascular Access
Safety
What do you need to do for Miscellaneous?
Hand hygiene
Provide for privacy of patient
Identify patient (2 identifiers)
Communicate with patient
Infection prevention
What do you need to assess for under neurological?
1) Level of Consciousness (LOC) 2.5
2) Pupils (PERRLA) 2.5
Motor control and response
3) Arm/hand bilateral 2.5
4) Leg/foot bilateral 2.5
What do you need to assess for with the Cardiovascular system?
Rhythm/Heart tones (2)
Skin
o Color/Temperature (1)
o Turgor/Moisture (1)
o Mucous membranes (1)
o Capillary refill (2)
Jugular Vein Distention (JVD) (1)
Peripheral pulses bilateral (2)
o Radial
o Dorsalis pedis (DP)
o Posterior tibial (PT)
Edema (5)
o Upper extremity
o Lower extremity
o Sacral
o Generalized
What do you need to assess for under Respiratory?
Respirations (2)
o Pattern/Effort
o Chest expansion
o Breath sounds anterior/posterior (A/P), bilateral
Incentive spirometer (IS) if applicable (2)
O2 device- type; amount administered (2)
Cough (productive /nonproductive) (1)
Secretions- Appearance/ Amount (1)
Chest tube (If applicable) 2
* How many
* Location of each
* Drainage
* Color
* Consistency
* Amount
* Suction
* Type
* CM of suction
* Air leak
What do you need to assess for under hemodynamics?
BP (systolic, diastolic, mean) (1)
* Heart Rate (1)
* Respiratory Rate (1)
* Temperature (1)
* Pulse oximeter (1)
Pain (5)
* PQRST
o Provokes
o Quality
o Radiates
o Severity 0-10
o Timing
What do you need to assess for under Gastrointestinal?
- Abdominal appearance (1)
- Auscultation (2)
- Palpation (2)
NG tube (if applicable) (2)
o Placement
o Drainage (Color & Amount)
o Placement verified
o Suction setting - Intermittent/Continuous
Last BM ( 1 point)
o Color/Appearance/Amount
o Incontinent?
Diet / Supplements (2points) - Ordered diet
- Percentage of diet eaten
- Supplements ordered
What do you need to assess for under Genitourinary?
Color
o Appearance (sediment/cloudy?)
o Drainage Method (if applicable)
o Amount
o Incontinent?
What do you need to assess for under wounds?
Location
* Size
* Stage (Pressure ulcer)
* Odor
* Sutures/ Staples
* Drainage (color/amount)
* Dressing change
What do you need to assess for under vascular access?
- Type of line/lines
- Location
- Site assessment
- IV Fluids (type and rate)
What do you need to assess for under safety?
Before leaving room:
* Call light in reach
* Bed in low position
* Ask patient if they need anything
* Path clear
* Assistive device in reach if applicable