Student Name _____________________
Video Link ____________________ Score_______
Instructions: Video yourself completing the assessment. Since your patient will be ‘well’, you should verbalize
expected findings as you proceed. Be sure that it is clear to the faculty what you are assessing so that we can ‘see
your thinking process’ and award points appropriately. Once you are satisfied with your performance, use the rubric
below to score yourself. Submit this self-evaluation along with the YouTube link to your video.
Hand Hygiene
Introduction
When you enter the room
Your name, role, purpose
Identify visitors
Scan for safety
S
U
Patient Identification
Check ID band
Begin to assess with conversation
S
U
Note name, DOB, MR #
Confirm with medical record
4
Ask to state name, DOB
Clear speech, coherent (3)
12
Airway and breathing
Open; unlabored (3)
Circulation
Skin, pink, warm, dry (3)
LOC
A&Ox3 (person, place, time) (3)
Allergies
Ask about allergies, check
armband
Determine reaction to allergen
4
VS & O2 Saturation
Interpret VS and compare to
previous
Discuss with patient
10
Pain
If yes, explore and scale
Choose appropriate scale
5
Tubes & Equipment
Check from source to patient
Note IVF/rate/patency; settings;output
5
Head
I = facial symmetry
mouth/teeth
PERRLA
symmetry noted, relaxed expression
Mouth pink, moist; teeth/dentures present/intact
Any trouble swallowing?
PERRLA, #mm
10
Chest
I = symmetrical expansion
A = heart and lung sounds
Ask about breathing/chest pain
Ant., lat. & post. lung sounds; Erb’s or apex
10
Abdomen
I = contour, distention,
dressings,drains
A = BS all 4 quadrants/frequency
P = palpate for tenderness,
firmness
Ask about voiding, last BM, N/V, diet/appetite
Dressing intact? type and amt drainage?
Surgical site intact; margins approximated?
S/Sx of infection?
10
Upper Extremities
I/P = both sides for color, temp.,
motion, sensation, strength; note
lesions,edema
Ask about numbness, weakness, tingling
Compare bilateral radial pulses for strength, regularity
10
Lower Extremities
I/P = both sides for color, temp.,
motion, sensation, strength; note
lesions,edema
Ask about numbness, weakness, tingling
Compare bilateral pedal pulses for strength, regularity
10
Skin Integrity
I =overall integrity
P= check turgor
Assess skin on back, buttucks
Inspect all pressure points
5
Identify & Assess
Perception of Care
Organization
“How are things going for you in the hospital?”
S
U
5