Physical assessment rubric with instructor

Question 1

how many major categories for assessment are there?

Answer 1

10

Question 2

What are the major categories and how many are there?

Answer 2

Miscellaneous
Neurological
Cardiovascular
Respiratory
Hemodynamics
Gastrointestinal
Genitourinary
Wounds/Incisions if applicable
Vascular Access
Safety

Question 3

What do you need to do for Miscellaneous?

Answer 3

Hand hygiene
Provide for privacy of patient
Identify patient (2 identifiers)
Communicate with patient
Infection prevention

Question 4

What do you need to assess for under neurological?

Answer 4

1) Level of Consciousness (LOC) 2.5
2) Pupils (PERRLA) 2.5
Motor control and response
3) Arm/hand bilateral 2.5
4) Leg/foot bilateral 2.5

Question 5

What do you need to assess for with the Cardiovascular system?

Answer 5

Rhythm/Heart tones (2)
Skin
o Color/Temperature (1)
o Turgor/Moisture (1)
o Mucous membranes (1)
o Capillary refill (2)
Jugular Vein Distention (JVD) (1)
Peripheral pulses bilateral (2)
o Radial
o Dorsalis pedis (DP)
o Posterior tibial (PT)
Edema (5)
o Upper extremity
o Lower extremity
o Sacral
o Generalized

Question 6

What do you need to assess for under Respiratory?

Answer 6

Respirations (2)
o Pattern/Effort
o Chest expansion
o Breath sounds anterior/posterior (A/P), bilateral
Incentive spirometer (IS) if applicable (2)
O2 device- type; amount administered (2)
Cough (productive /nonproductive) (1)
Secretions- Appearance/ Amount (1)
Chest tube (If applicable) 2
* How many
* Location of each
* Drainage
* Color
* Consistency
* Amount
* Suction
* Type
* CM of suction
* Air leak

Question 7

What do you need to assess for under hemodynamics?

Answer 7

BP (systolic, diastolic, mean) (1)
* Heart Rate (1)
* Respiratory Rate (1)
* Temperature (1)
* Pulse oximeter (1)
Pain (5)
* PQRST
o Provokes
o Quality
o Radiates
o Severity 0-10
o Timing

Question 8

What do you need to assess for under Gastrointestinal?

Answer 8

• Abdominal appearance (1)
• Auscultation (2)
• Palpation (2)
  NG tube (if applicable) (2)
  o Placement
  o Drainage (Color & Amount)
  o Placement verified
  o Suction setting
• Intermittent/Continuous
  Last BM ( 1 point)
  o Color/Appearance/Amount
  o Incontinent?
  Diet / Supplements (2points)
• Ordered diet
• Percentage of diet eaten
• Supplements ordered

Question 9

What do you need to assess for under Genitourinary?

Answer 9

Color
o Appearance (sediment/cloudy?)
o Drainage Method (if applicable)
o Amount
o Incontinent?

Question 10

What do you need to assess for under wounds?

Answer 10

Location
* Size
* Stage (Pressure ulcer)
* Odor
* Sutures/ Staples
* Drainage (color/amount)
* Dressing change

Question 11

What do you need to assess for under vascular access?

Answer 11

• Type of line/lines
• Location
• Site assessment
• IV Fluids (type and rate)

Question 12

What do you need to assess for under safety?

Answer 12

Before leaving room:
* Call light in reach
* Bed in low position
* Ask patient if they need anything
* Path clear
* Assistive device in reach if applicable