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iRubric: PN Head to Toe Assessment rubric

iRubric: PN Head to Toe Assessment rubric

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PN Head to Toe Assessment 
Nurse head-to-toe assessment rubric
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: KX7BX27
By debipn
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
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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