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iRubric: Abdominal Assessment rubric
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Abdominal Assessment
H&P Practical - Abdomen
Rubric Code:
UA6CBW
By
hblotzer
Ready to use
Public Rubric
Subject:
Nursing
Type:
Assessment
Grade Levels:
Graduate
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Element
Attempted Satisfactorily
3 pts
Attempted - Needs Improvement
2 pts
Attempted - Unacceptable
1 pts
Did Not Attempt
0 pts
Abdomen Exposed
Attempted Satisfactorily
Abdomen exposed from xiphoid process to symphysis pubis
Attempted - Needs Improvement
Abdomen was not adequately exposed from either the xiphoid process OR symphysis pubis
Attempted - Unacceptable
Abdomen was not adequately exposed from both the xiphoid process and symphysis pubis
Did Not Attempt
The abdomen was not exposed
Inspected Abdomen
Attempted Satisfactorily
 Position the client in a supine position
 Observe the position of the umbilicus
 Observe skin color.
 Observe the location and characteristics of lesions, scars, and abdominal markings inspected for striae, or "stretch marks," and surgical scars
 Observe the abdomen for symmetry, bulging, or masses
 Observe the abdominal wall for movement.
Inspected abdomen and verbalized assessment of; 1-skin, 2-umbilicus, 3-contou
Attempted - Needs Improvement
Inspected abdomen and verbalized 3 areas of assessment
Attempted - Unacceptable
Inspected abdomen and verbalized 1-2 areas of assessment
Did Not Attempt
Did not verbalize inspection of the abdomen
Auscultated Abdomen
Attempted Satisfactorily
Auscultated abdomen and verbalized assessment of; 1-bowel sounds, 2-bruits
Attempted - Needs Improvement
Auscultated the abdomen and verbalized 1 area of assessment
Attempted - Unacceptable
Auscultated the abdomen, but did not verbalize assessment
Did Not Attempt
Did not auscultate the abdomen
Percussed Abdomen
Attempted Satisfactorily
Percussed abdomen in all four quadrants, verbalized notation of distribution of tympany and dullness
Attempted - Needs Improvement
Percussed abdomen in all four quadrant, verbalized notation of distribution of tympany OR dullness
Attempted - Unacceptable
Percussed abdomen in 1-3 areas and/or did not verbalize what they were noting
Did Not Attempt
Did not percuss the abdomen
Percussed and Measured Vertical Liv
Attempted Satisfactorily
Percussed for liver span in midclavicular line, making a mark on the patient's skin, starting at the nipple line percussing down and then starting at a level below the umbilicus and percussing up. Measured the distance between the two points in cm. Had patient displace breast as necessary
Attempted - Needs Improvement
Technique for liver percussion was correct, but did not accurately distinguish percussion notes. Measured the liver in cm.
Attempted - Unacceptable
Did not measure liver span in midclavicular line, started too high on the chest or too low in the abdomen, did not mark and measure the liver span in cm, and/or did not have pt. displace the breast (if necessary)
Did Not Attempt
Did not percuss and measure liver span
Palpated Lightly
Attempted Satisfactorily
Palpated lightly in all four quadrants, verbalizing assessment for; 1-any tenderness, 2-muscular resistance, 3-mass
Attempted - Needs Improvement
Palpated lightly in all 3-4 quadrants, verbalized 3 areas of assessment
Attempted - Unacceptable
Palpated lightly in 1-2 quadrants, did not verbalize assessment, or palpated too firmly
Did Not Attempt
Did not palpate lightly
Palpated for Liver
Attempted Satisfactorily
Palpated for an enlarged liver, using the "hooking technique" or by using the left hand to support the posterior right 11th and 12th ribs, and the right hand below the lower border of liver dullness; asked patient to take a deep breath while moving right fingers upward and having patient exhale, feeling for the liver
Attempted - Needs Improvement
Did not palpate firmly enough to adequately assess
Attempted - Unacceptable
Palpated too firmly or did not use correct technique
Did Not Attempt
Did not palpate for the liver
Palpated for Spleen
Attempted Satisfactorily
Palpated for an enlarged spleen, with left hand reaching over and supporting the lower left rib cage and the right hand below the left costal margin; pressed in toward the spleen, asked patient to take a deep breath, feeling for an enlarged spleen when pt. exhaled
Attempted - Needs Improvement
Did not palpate firmly enough to adequately assess
Attempted - Unacceptable
Palpated too firmly or did not use correct technique
Did Not Attempt
Did not palpate for an enlarged spleen
Palpated for Width of Aorta
Attempted Satisfactorily
Palpated firmly in upper abdomen, slightly to the left of midline, paused to identify the aortic pulsations
Attempted - Needs Improvement
Location was slightly incorrect
Attempted - Unacceptable
Did not pause to identify pulsations, location was incorrect, and/or pressed too firmly
Did Not Attempt
Did not palpate for width of the aorta
Subjects:
Medical
Nursing
Types:
Assessment
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