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iRubric: PN Head to Toe Assessment rubric

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PN Head to Toe Assessment PN Head to Toe Assessment Students are required to perform nursing skills with accurate 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: HX9W9BA By gwlasowicz Ready to use Public Rubric Subject: Nursing Type: Assessment Grade Levels: 9-12, Graduate

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 Rights: Knocks on door, greet resident, introduces self, wash hands, check patient ID bracelet after washing hands and asks for 2 pt identifiers,provides privacy , lock wheels to bed,w/c, Set up for procedureSafety: bed locked; bed at waist level States what they are going to do; maintains privacy of pt throughout assessment including keeping pt covered as much as possible	Advanced Performs all initial steps without difficulty that are required in the skill listed. Recognizes, verbalizes, and demonstrates all critical steps in a logical manner consistently without difficulty.	Proficient Performs more than 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 or did not verify patient ID with 2 identifiers without prompting.	Below Basic Does not perform any of the initial steps required in the skill listed, or indirect care measures 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/Communication Student explains to examiner steps of procedure while performing	Advanced Verbalizes relevant information relating to the skill being checked off on. Answers instructor's questions regarding the skill and its importance plus the impact to the client without difficulty.	Proficient Able to verbalize relevant information relating to the designated skill that is being checked off on. Able to answer more than four questions regarding the skill and its importance re garding the skill and its importance plus the impact to the client.	Basic Limited ability to verbalize relevant information relating to the designated skill that is being checked off on. 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. Unable to answer instructor's questions regarding the skill and its importance and/or impact to the client.
VS Radial pulse: RR: SaO2: T: BP:	Advanced Accurate assessment of VS; no errors	Proficient Mostly accurate assessment of VS; had 1 re-do	Basic Had to re-do more than one VS or a VS twice	Below Basic Needs much more practice assessing VS. Had to redo more than one VS twice or had to redo one VS more than two times before accurate assessment.
Integument Skin: Nails: Turgor: Mucous membranes: Asks questions	Advanced Assesses all aspects;requires little to no prompting	Proficient Misses only 1 assessment point requires occasional prompting	Basic misses 2-3 assessment points; requires some prompting	Below Basic misses multiple assessment points and requires frequent prompting
Head Head/Hair: Face:Symmetry,asks patient to smile,asks patient to stick out tongue	Advanced Assesses all aspects;requires little to no prompting	Proficient Misses only 1 assessment point requires occasional prompting	Basic misses 2-3 assessment points; requires some prompting	Below Basic misses multiple assessment points and requires frequent prompting
Eyes and Vision Eyes: The sclera PERRLA (pupils equally round respond to light accommodation) Asks about use of glasses/contacts or other vision problems	Advanced Assesses all aspects;requires little to no prompting	Proficient Misses only 1 assessment point requires occasional prompting	Basic misses 2-3 assessment points; requires some prompting	Below Basic misses multiple assessment points and requires frequent prompting
Ears and Hearing Ears: Hearing:Use of hearing aid/asks about problems	Advanced Assesses all aspects;requires little to no prompting	Proficient Misses only 1 assessment point requires occasional prompting	Basic misses 2-3 assessment points; requires some prompting	Below Basic misses multiple assessment points and requires frequent prompting
Nose and Sinus Nose: Mouth: Teeth and Gums: Dentures/Partials/Chewing problems The tongue: Mucous membranes	Advanced Assesses all aspects;requires little to no prompting	Proficient Misses only 1 assessment point requires occasional prompting	Basic misses 2-3 assessment points; requires some prompting	Below Basic misses multiple assessment points and requires frequent prompting
Neck Swallowing Swelling	Advanced Assesses all aspects;requires little to no prompting	Proficient Misses only 1 assessment point requires occasional prompting	Basic misses 2-3 assessment points; requires some prompting	Below Basic misses multiple assessment points and requires frequent prompting
Thorax, Lungs, and Abdomen Lungs / Chest: Auscultates Ant & Post. Asks about smoking & health hx Heart/Circulation:Radial pulse, Capillary refill;asks about health hx GI:Assesses in correct order;asks about BM;Health Hx; asks about diet GU:Asks about UOP and health hx; asks about fluid intake	Advanced Assesses all aspects;requires little to no prompting	Proficient Misses only 1 assessment point requires occasional prompting	Basic misses 2-3 assessment points; requires some prompting	Below Basic misses multiple assessment points and requires frequent prompting
Extremities The extremities Muscles:Strength including grips Joints: ROM Gait: walking difficulties;use of assistive devices/limitations Pedal pulses Able to perform ADL's without assist?	Advanced Assesses all aspects;requires little to no prompting	Proficient Misses only 1 assessment point requires occasional prompting	Basic misses 2-3 assessment points; requires some prompting	Below Basic misses multiple assessment points and requires frequent prompting
Medications Asks about current medication use including OTC /Herbal Allergies	Advanced Assesses all aspects;requires little to no prompting	Proficient Misses only 1 assessment point requires occasional prompting	Basic misses 2-3 assessment points; requires some prompting	Below Basic misses multiple assessment points and requires frequent prompting
Attendance and Mannerism On time, prepared to perform skills, professional attire and attitude Performs assessment in a timely manner	Advanced On time to lab skills check offs. Calm demeanor with appropriate mannerisms Performed assessment with efficiency.	Proficient On time to lab skills check offs. Appears nervous yet able to continue with check off with some distraction. Mannerisms are appropriate. Performed assessment in a minimal amount of time.	Basic Absent or Tardy to skills check off. Instructor notices that the student has limited ability to check off for the designated skill at this time. Body language and mannerisms are inappropriate at times. Took a little long to complete assessment. Needs to improve on efficiency of tasks.	Below Basic Absent or Tardy to check off. Instructor is notices that the student is not prepared to check off at this time. Student is not familiar with the designated skill . Frustration noted. Body language and mannerisms are inappropriate for most of the check off. Took a very long time to complete assessment. Needs to learn time management skills to be more efficient.
Final Steps & Lab Area Indirect Care- Safety- bed locked, call light in reach,w/locked, bed low position Resident Rights: privacy curtan opened. Comfort: pillow, blanket, repositioned, Infection Control, trash empty, wash hands; states going to document when leaving room	Advanced Able to do all of the following: a.verbalize final steps. b. mention documentation of skill c. mention client response to skill performed d.clean up after the skill is performed. Bed is returned to the lowest position. Mentions call bell is placed within reach Maintains privacy. Respectful to the mannequin.	Proficient One of the following occurs: Fails to: a. verbalize final steps. b. mention documentation of skill. c.mention client response to skill performed. d.clean up after the skill is performed. Bed is left in high position. Does not mention call bell is placed within reach. Privacy is not maintained. Disrespectful to the mannequin.	Basic Two or more of the following occurs: Fails to: a.verbalize final steps. b.mention documentation of skill. c. mention client response to skill performed. d. clean up after skill is performed. Bed is left in high position. Does not mention call bell is placed within reach. Privacy is not maintained for mannequin. Disrespectful to the mannequin.	Below Basic Three or more of the following occurs: Fails to: a.verbalize final steps. b.mention documentation of skill. c.mention client response to skill performed d.clean up after skill is performed. Bed is left in high position. Does not mention call bell is placed wthin reach. Privacy not maintained for mannequin Disrespectful to the mannequin.

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