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iRubric: Abdominal Assessment rubric

iRubric: Abdominal Assessment rubric

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Abdominal Assessment Abdominal Assessment Rubric Code: RX8875X By debi71 Ready to use Public Rubric Subject: Nursing Type: Assessment Grade Levels: Graduate

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

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