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iRubric: Nursing Health Assessment Simulation/ Skill rubric

iRubric: Nursing Health Assessment Simulation/ Skill rubric

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Nursing Health Assessment Simulation/ Skill 
Nursing Health Assessment Simulation/ Skill
Rubric Code: XXCC2A7
By holliehild
Ready to use
Public Rubric
Subject: Nursing  
Type: Assessment  
Grade Levels: Undergraduate

Powered by iRubric Initial Nursing Assessment Simulati
Enter rubric description
  Unacceptable

Unacceptable performance, failing. Student should seek full review and reassessment.

1 pts

Marginal

Marginal performance, student does not meet expectations. Student should seek review and reassessment.

2 pts

Satisfactory

Satisfactory performance, meets expectations. Student is passing.

3 pts

Uses Universal Precautions

The nursing student employs universal precautions throughout patient interaction. (APPLY)
Unacceptable

Uses no element of universal precautions throughout patient interaction.
Marginal

Uses most elements of universal precautions throughout most of patient interaction.
Satisfactory

Uses all elements of universal precautions throughout all patient interaction.
Identify Patient

The nursing student appropriately identifies patient. (APPLY)
Unacceptable

Does not identify patient.
Marginal

Identifies patient without using all patient identifiers (patient states name and date of birth, name bracelet). No clarification of incongruence sought.
Satisfactory

Identifies patient using using all patient identifiers (patient states name/date of birth), name bracelet verified). Seeks clarification if incongruent.
Pain Assessed / Vital signs

The nursing student explains and assesses pain using numeric scale, obtains vital signs and documents findings appropriately. (EVALUATE)
Unacceptable

Does not address pain assessment or vital signs. Does not document.
Marginal

Assesses pain without appropriately utilizing pain scale. Does not obtain all vital signs. Does not document appropriately.
Satisfactory

Assesses pain using pain scale by fully explaining scale and meaning. Complete Vital signs obtained. Documents appropriately.
Recognizes Changes in Condition

The nursing student recognizes changes in patient status which require immediate intervention and documents appropriately. (EVALUATE)
Unacceptable

Does not recognize need for intervention. Does not document.
Marginal

Recognizes some status changes, but interventions are inappropriate or incomplete. Does not document all status changes.
Satisfactory

Recognizes all status changes and intervenes appropriately, reassesses. Documents appropriately.
General Survey

The nursing student recognizes
• Body Build
• Appearance
• Facial Expressions
and documents appropriate findings. (EVALUATE)
Unacceptable

Does not include general survey in assessment.
Marginal

Recognizes some of the general survey attributes, but not all. Does not document all findings.
Satisfactory

Recognizes and documents findings relating to general survey of the overall health of the client.
Cognitive Orientation Assessed

The nursing student establishes cognitive orientation status and documents findings appropriately.
• LOC and Orientation

• Eyes & Pupils (with pen light)
• Grips and Pushes
Ears
(EVALUATE)
Unacceptable

Does not assesses cognitive orientation in assessment.
Marginal

Assesses cognitive orientation incompletely, or late. Does not document all status changes.
Satisfactory

Assesses cognitive orientation appropriately as part of initial assessment. Documents appropriately.
Cardiovascular

The nursing student assess cardiovascular function of client and documents findings appropriately.
• Apical (must auscultate), Radial, and Pedal Pulses
• Capillary Refill
• Carotid Pulse, Jugular Neck Veins
• Skin, Mucous Membranes,Edema
• Calf Tenderness
• Heart Rhythm
(EVALUATE)
Unacceptable

Does not include cardiovascular in assessment.
Marginal

Does not complete all aspects of the cardiovascular assessment. Does not document all findings of the cardiovascular assessment.
Satisfactory

Completes and documents all portions of the cardiovascular assessment.
Respiratory

The nursing student assesses respiratory system appropriately and documents findings appropriately.
• Respirations
• Lung Sounds (Posterior and Anterior)
• Cough
• Oxygen
(EVALUATE)
Unacceptable

Does not include respiratory in assessment.
Marginal

Assesses breath sounds incompletely. (For example does not provide instructions to patient, does not assess all lung fields, does not reposition patient if needed)
Does not include all components of the respiratory assessment, does not document these findings appropriately.
Satisfactory

Assesses respiratory system appropriately. Includes all aspects of the assessment and documents appropriately.
Gastrointestinal

The nursing student will assess the gastrointestinal system and document findings appropriately.
• Oral
• Abdomen: Inspect/Auscultate/Palpate
• Bowel Sounds, Bowel Movement, Nutrition
(EVALUATE)
Unacceptable

Does not include GI system in assessment.
Marginal

Does not include all assessment of GI. Does not document all findings of GI.
Satisfactory

Assesses GI system appropriately. Documents findings appropriately.
Genitourinary

The nursing student assesses the genitourinary system appropriately and documents findings.
• Urine
• Catheter
• Genitalia
(EVALUATE)
Unacceptable

Does not include GU system in assessment.
Marginal

Does not include all assessment of GU. Does not document findings appropriately.
Satisfactory

Assesses GU system appropriately and documents findings appropriately.
Musculoskeletal

The nursing student assesses the musculoskeletal system appropriately and documents findings.
• Mobility
• Treatments
• Contractures, Amputations
• ROM
(EVALUATE)
Unacceptable

Does not include the musculoskeletal system in assessment.
Marginal

Does not include entire assessment of the musculoskeletal system. Does not document findings appropriately.
Satisfactory

Assesses the musculoskeletal system appropriately and documents findings appropriately.
Integumentary

The nursing student assesses the Integumentary System appropriately and documents findings.
• Appearance
• Temperature
• Pressure Sores/Wounds
• Dressings
(EVALUATE)
Unacceptable

Does not include the Integumentary system in assessment.
Marginal

Does not include all the Integumentary system in assessment. Does not document appropriately.
Satisfactory

Assesses the Integumentary system appropriately and documents findings appropriately.
Miscellaneous

Behavior, Restraints, Languages spoken, Allergies
Unacceptable

Does not include the Miscellaneous items in assessment.
Marginal

Does not include all the miscellaneous items in assessment. Does not document appropriately.
Satisfactory

Assesses the miscellaneous items appropriately and documents findings appropriately.



Keywords:
  • nursing, assessment, simulation

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