4 pts
3 pts
2 pts
1 pts
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
Student explains to examiner steps of procedure while performing
Radial pulse: RR: SaO2: T: BP:
Skin: Nails: Turgor: Mucous membranes: Asks questions
Head/Hair: Face:Symmetry,asks patient to smile,asks patient to stick out tongue
Eyes: The sclera PERRLA (pupils equally round respond to light accommodation) Asks about use of glasses/contacts or other vision problems
Ears: Hearing:Use of hearing aid/asks about problems
Nose: Mouth: Teeth and Gums: Dentures/Partials/Chewing problems The tongue: Mucous membranes
Swallowing Swelling
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
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?
Asks about current medication use including OTC /Herbal Allergies
On time, prepared to perform skills, professional attire and attitude Performs assessment in a timely manner
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