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Nurse head-to-toe assessment rubric 
Nurse head-to-toe assessment rubric
Students are required to perform nursing skills with 100 % proficiency. In addition to skills performance of skills, students must use critical thinking skills to include indirect care measures:safety, infection control, comfort measures, resident rights.
Rubric Code: FX9W9BC
By gwlasowicz
Ready to use
Public Rubric
Subject: Nursing  
Type: Assessment  
Grade Levels: 9-12, Graduate

Powered by iRubric Lab Skill
Nursing Assistant Skill Checklist Assessment
  Advanced

4 pts

Proficient

3 pts

Basic

2 pts

Below Basic

1 pts

Initial Steps of skills

Indirect Care Measures,<BR>
Rights: Knocks on door, greet resident, introduces self, wash hands, check patient ID bracelet after washing hands, privacy curtain, lock wheels to bed,w/c,<BR>
Set up for procedure
Advanced

Performs all initial steps without difficulty that are required in the skill listed.
Proficient

Performs more than<BR>
three initial steps required in the skill performance or 75% of combined skill and indirect care measures
Basic

Performs less than two initial steps required in the skill listed, or 50 % of the combined skill and indirect care measures
Below Basic

Does not perform any of the initial steps required in the skill listed, or indirect care measures
Indirect Care/Critical Steps

Safety: lock wheels to bed.w/c, call light, uncluttered room,bed low position<BR>
infection control: wash hands, empty trash<BR>
comfort: reposition, pillows, blankets, water<BR>
rights; address by name, introduce self, open curtain when not in use, privacy, knock on door before entering
Advanced

Recognizes, verbalizes, and demonstrates all critical steps in a logical manner consistently without difficulty.
Proficient

Recognizes, verbalizes, and demonstrates the critical steps in a logical manner 7% of the time during this check off.
Basic

Able to recognize, verbalize, and demonstrate the critical steps in a logical manner 50of the time during this check off.
Below Basic

Fails to recognize, verbalize, and/or demonstrate the critical steps in a logical manner less than 25%f the time during this check off.
Rationale

Student explains to examiner steps of procedure while performing
Advanced

Verbalizes relevant information relating to the skill being checked off on.<BR>
Answers instructor's questions regarding the skill and its importance plus the impact to the client<BR>
without difficulty.
Proficient

Able to verbalize relevant information relating to the designatedt<BR>
skill that is being checked off on.<BR>
Able to answer more than four questions regarding the skill and its importance re<BR>
garding the skill and its importance <BR>
plus the impact to the<BR>
client.
Basic

Limited ability to verbalize relevant information relating to the designated <BR>
skill that is being checked off on.<BR>
Able to answer less than three questions regarding the skill and its importance plus the impact to the client.
Below Basic

Fails to verbalize relevant information relating to the skill being checked off on.<BR>
Unable to answer instructor's questions regarding the skill and its importance and/or impact to the client.
Integument

Skin:
Nails:
Advanced

Assesses all aspects
Proficient

Misses only 1 assessment point
Basic

misses 2-3 assessment points
Below Basic

misses multiple assessment points and unorganized
Head

Head/Hair:
Skull:
Face:
Advanced

Assesses all aspects
Proficient

Misses only 1 assessment point
Basic

misses 2-3 assessment points
Below Basic

misses multiple assessment points and unorganized
Eyes and Vision

Eyebrows:
Eyelashes:
Eyelids:
Eyes:
The sclera
Cornea
PERRLA (pupils equally round respond to light accommodation)
Assess the peripheral visual field
Snellin Test
Extraocular Muscle assessment
Advanced

Assesses all aspects
Proficient

Misses only 1 assessment point
Basic

misses 2-3 assessment points
Below Basic

misses multiple assessment points and unorganized
Ears and Hearing

Ears:
Hearing:
Advanced

Assesses all aspects
Proficient

Misses only 1 assessment point
Basic

misses 2-3 assessment points
Below Basic

misses multiple assessment points and unorganized
Nose and Sinus

Nose:
Mouth:
Teeth and Gums:
The tongue:
Soft palate:
Advanced

Assesses all aspects
Proficient

Misses only 1 assessment point
Basic

misses 2-3 assessment points
Below Basic

misses multiple assessment points and unorganized
Neck

The neck
The lymph nodes
The trachea:
The thyroid gland: swallowing:
Advanced

Assesses all aspects
Proficient

Misses only 1 assessment point
Basic

misses 2-3 assessment points
Below Basic

misses multiple assessment points and unorganized
Thorax, Lungs, and Abdomen

Lungs / Chest:
Heart:
Abdomen:
Advanced

Assesses all aspects
Proficient

Misses only 1 assessment point
Basic

misses 2-3 assessment points
Below Basic

misses multiple assessment points and unorganized
Extremities

The extremities
Muscles: .
Bones:
Joints:
Advanced

Assesses all aspects
Proficient

Misses only 1 assessment point
Basic

misses 2-3 assessment points
Below Basic

misses multiple assessment points and unorganized
Attendance and Mannerism

On time, prepared to perform skills, professional attire and attitude
Advanced

On time to lab skills check offs.<BR>
Calm demeanor with<BR>
appropriate mannerisms
Proficient

On time to lab skills check offs.<BR>
Appears nervous yet able to continue with check off with some distraction. <BR>
Mannerisms are appropriate.
Basic

Absent or Tardy to skills check off.<BR>
Instructor notices that the student has limited ability to check off for the designated skill at this time.<BR>
Body language and mannerisms are inappropriate at times.
Below Basic

Absent or Tardy to check off.<BR>
Instructor is notices that the student is not prepared to check off at this time.<BR>
Student is not familiar with the designated skill .<BR>
Frustration noted.<BR>
Body language and mannerisms are inappropriate for most of the check off.
Final Steps & Lab Area

Indirect Care- Safety- bed locked, call light,w/clocked, bed low position<BR>
Resident Rights: privacy curtan opened. <BR>
Comfort: pillow, blanket, repositioned, <BR>
Infection Control, trash empty, wash hands
Advanced

Able to do all of the following:<BR>
a.verbalize final steps.<BR>
b. mention documentation of skill.<BR>
c. mention client response to skill performed.<BR>
d.clean up after the skill is performed.<BR>
Bed is returned to the lowest position.<BR>
Mentions call bell is placed within reach.<BR>
Maintains privacy.<BR>
Respectful to the mannequin.
Proficient

One of the following occurs:<BR>
Fails to:<BR>
a. verbalize final steps.<BR>
b. mention documentation of skill.<BR>
c.mention client response to skill performed.<BR>
d.clean up after the skill is performed.<BR>
Bed is left in high position.<BR>
Does not mention call bell is placed within reach.<BR>
Privacy is not maintained. <BR>
Disrespectful to the mannequin.
Basic

Two or more of the following occurs:<BR>
Fails to:<BR>
a.verbalize final steps. <BR>
b.mention documentation of skill.<BR>
c. mention client response to skill performed.<BR>
d. clean up after skill is performed.<BR>
Bed is left in high position. <BR>
Does not mention call bell is placed within reach.<BR>
Privacy is not maintained for mannequin. <BR>
Disrespectful to the mannequin.
Below Basic

Three or more of the following occurs:<BR>
Fails to:<BR>
a.verbalize final steps.<BR>
b.mention documentation of skill.<BR>
c.mention client response to skill performed.<BR>
d.clean up after <BR>
skill is performed.<BR>
Bed is left in high position.<BR>
Does not mention call bell is placed wthin reach.<BR>
Privacy not maintained for mannequin<BR>
Disrespectful to the mannequin.




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