Physical assessment rubric with instructor Flashcards

1
Q

how many major categories for assessment are there?

A

10

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2
Q

What are the major categories and how many are there?

A

Miscellaneous
Neurological
Cardiovascular
Respiratory
Hemodynamics
Gastrointestinal
Genitourinary
Wounds/Incisions if applicable
Vascular Access
Safety

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3
Q

What do you need to do for Miscellaneous?

A

Hand hygiene
Provide for privacy of patient
Identify patient (2 identifiers)
Communicate with patient
Infection prevention

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4
Q

What do you need to assess for under neurological?

A

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

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5
Q

What do you need to assess for with the Cardiovascular system?

A

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

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6
Q

What do you need to assess for under Respiratory?

A

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

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7
Q

What do you need to assess for under hemodynamics?

A

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

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8
Q

What do you need to assess for under Gastrointestinal?

A
  • 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
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9
Q

What do you need to assess for under Genitourinary?

A

Color
o Appearance (sediment/cloudy?)
o Drainage Method (if applicable)
o Amount
o Incontinent?

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10
Q

What do you need to assess for under wounds?

A

Location
* Size
* Stage (Pressure ulcer)
* Odor
* Sutures/ Staples
* Drainage (color/amount)
* Dressing change

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11
Q

What do you need to assess for under vascular access?

A
  • Type of line/lines
  • Location
  • Site assessment
  • IV Fluids (type and rate)
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12
Q

What do you need to assess for under safety?

A

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

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