sS Uu NP Comments ____ ___________________________ 3,. Explained procedure, avoided facial gestures ____ ____ ___________________________ ____ reflecting concern. ____ ____ ___________________________ ____ ____ ___________________________ 4. Ensurred that room was quiet. ____ ____ ____ ___________________________ 5,. Assessed the heart: ____ ____ ___________________________ ____ ____ ___________________________ a. Formed a mental image of the exact location ____ ____ ___________________________ ____ ____ ___________________________ of the heart. ____ ____ ____ ___________________________ ____ b. Found the angle of Louis, slipped finger ____ ___________________________ ____ ____ ___________________________ down each side to feel adjacent ribs. ____ ____ ____ ___________________________ ____ ____ ___________________________ c. Found the following anatomic landmarks:: ____ ____ ___________________________ (1)) The aortic area. ____ ____ ____ ___________________________ ((22)) The pulmonic area. ____ ____ ____ ___________________________ ____ ____ ___________________________ (3)) The second pulmonic area. ____ ____ ____ ___________________________ ____ (4)) The tricuspid area.. ____ ____ ___________________________ ____ ((55)) The mitral area. ____ (6)) The epigastric area.. ____ d. Stood to the patient'’s right, inspected and ____ palpated the precordium, noted visible pul- sations and more exaggerated lifts, palpated for pulsations at all landmarks. e. Located PMI. ____ f. Turned patient onto left side if necessary. ____ g. Inspected epigastric area,, palpated abdomi- ____ nal aorta, noted a localized strong beat. hh. Aussccultated heart sounds properlyy. (1)) Positioned patient appropriatelyy. ____ ((22)) Asked patient not to speak but to breathe ____ comfortablyy, began with diaphragm of the stethoscope and alternated with the bell, avoided jumping from one area to anothherr. (3)) Movedd systematically around the heart ____ sound locations in the proper order. ((44)) Listened for S22 at each site. ____ ____ (5)) Counted each lub-dub as one heartbeat, counted number of beats for 1 minute. (6)) Assessseedd heart rhythm by noting time ____ between S11 and S2 and time between S2 and the next S1, listened to the full cycle at each area, noted regular intervals be- tween each sequence. 5iO0 Copyright ©© 2018 by Elsevier Inc. All rights reserved.
sS Uu NP Comments (7) Compared apical and radial pulses when heart rate is irregularr, asked a colleague for assistance if needed.. ____ ____ ____ ___________________________ i. Auscultated for extra heart sounds at each site, noted pitch, loudness, duration, timing, location on chest wall, and where heard in cardiac cycle.. (1) Listened for low-pitched extra sounds witthh the bell of the stethoscope. ____ ____ ____ ___________________________ (2) Positioned patient properlyy, asked pa- tient to hold breatthh,, listened for friction rubs.. ____ ____ ____ ___________________________ jj. Auscultated for heart murmurs over each auscultation site.. (1) Noted intensity and location where yyou ____ ____ ____ ___________________________ can best hear any murmur detected. (2) Noted pitch of the murmur. ____ ____ ____ ___________________________ 6.. Assessedd neck vessels:: a. Positioned patient appropriatelyy. ____ ____ ____ ___________________________ b. Inspected both sides of neck for obvious arte- ____ ____ ____ ___________________________ rial ppuulsations. c. Palpated each carotid artery appropriately; asked patient to raise chin slightly; noted rate, rrhythm, strength, and elasticity; noted ____ ____ ____ ___________________________ if pulse changed during breathing.. d. Auscultated for blowing sound over each carotid arteerryy with bell of stethoscope, asked patientt to hold a breatthh for a few heartbeats so rreesspiratory sounds do not interfere with ____ ____ ____ ___________________________ aauussccultation. 7.. Performed peripheral vascular assessment: a. Inspected lower extremities for changes in color and conditions of the skin, compared skin color with patient lying and standing. ____ ____ ____ ___________________________ b. Palpated edematous areas, noted mobilityy, ____ ____ ____ ___________________________ consistencyy, and tenderness. c. Assessed for pitting edema properlyy. ____ ____ ____ ___________________________ d. Measured circumference of extremity with ttaappee mmeeaassuurree.. ____ ____ ____ ___________________________ e. Checked capillary refill properlyy. ____ ____ ____ ___________________________ f. Asked if patient experienced pain or tender- ness, checked for signs of phlebitis or DVTT. ____ ____ ____ ___________________________ Copyright ©© 20188 by Elsevier Inc.. All rights reserved.. 51
sS Uu NP Comments g.. Palpated each peripheral arteryy for equal- ityy and elasticityy starting at the distal end of each,, noted ease with whichh it sprang back and strength of pulse. (1)) Palpated radial pulse properlyy.. ____ ____ ____ ___________________________ ((22)) Palpated ulnar pulse properlyy.. ____ ____ ____ ___________________________ (3)) Palpated bracchhiiaal pulse properlyy.. ____ ____ ____ ___________________________ (4)) Positioned patient appropriatelyy, palpat- ed dorsalis pedis pulse properlyy. ____ ____ ____ ___________________________ (5)) Palpated posterior tibial pulse properlyy. ____ ____ ____ ___________________________ (66)) Palpated popliteal pulse properlyy, re- positioned patient if needed. ____ ____ ____ ___________________________ (7)) Applied gglloves, positioned patient prop- erlyy,, palpated femoral pulse properlyy.. ____ ____ ____ ___________________________ h.. Used a Doppler instrument if necessaryy. (1)) Applied conducting gel to either pa- tient'’s skin or transducer tip of probe, turned on Dopplerr. ____ ____ ____ ___________________________ (2)) Applied ultrasound probee to skin, changed Doppler angle until pulsation is audible, wiped gel from patient and Dopplerr.. ____ ____ ____ ___________________________ 8.. Removed ggloves, discarded used supplies and glovee appropriatelyy, helped patient to comfort- able pposition, performed hand hyygiene. ____ ____ ____ ___________________________ EVALUATTIION 1.. Commpparred findings with normal assessment ____ ____ ____ ___________________________ characteristics of heart and vascular syystem. 2.. Asked anotherr nnurse to confirm assessment if heart sounds are not audible or pulses are not ____ ____ ____ ___________________________ palpable. 3.. Asked patient to describe behaviors that ____ ____ ____ ___________________________ increase risk for heart and vascular disease. 4.. Commppaarred pulses and capillaryy refill bbiillaterallyy ____ ____ ____ ___________________________ with previous assessment. 5.. Identified unexpected outcomes.. ____ ____ ____ ___________________________ RREECCOORRDDIINNGG AANNDD RREEPPOORRTTIINNGG ____ ____ ____ ___________________________ 1. Documented quality, intensity, rate, and rhythm 1. oDfohceuamrtesnotuedndqsuaanlidty,pienrtiepnhseitrya,lrpautel,seasndinrahpypthrom- priate record. 2.. Documented additional cardiaacc findings, JJVPP, and condition of extremities in appropriate ____ ____ ____ ___________________________ record. 5522 Copyright ©© 2018 by Elsevier Inc. All rights reserved.
sS uU NP Comments 3.. Documented activitty level and subjective data related to fatigue, shortness of breath, and cheesst ppaaiinn.. ____ ____ ____ ___________________________ 4.. Documented evaluation of ppatient learning. ____ ____ ____ ___________________________ 5.. Reported any irregularities in heart function and indications of impaired arterial blood flow immediatelyy to health care proviiddeerr. ____ ____ ____ ___________________________ 6.. Reported changeess in peripheral circulation to health caree prrooviiddeerr.. ____ ____ ____ ___________________________ Coppyyrriightt ©© 201188 by Elsevier Inc.. AAll rights reserved. 53
Student ______________________________________________________ Date _________________________ nstructor ____________________________________________________ Date _________________________ PERFORMANCE CHECKLIST SKILL 6.5 ABDOMINAL ASSESSMENT S U NP Comments ASSESSMENT ____ ____ ____ __________________________ 1. Assessed character of any reported abdominal ____ ____ ____ __________________________ ____ ____ ____ __________________________ or lower back pain. ____ ____ __________________________ ____ ____ ____ __________________________ 2. Observed patient’s movement and position. ____ ____ __________________________ ____ ____ ____ __________________________ 3. Assessed patient’s normal bowel habits. ____ ____ ____ __________________________ ____ ____ __________________________ 4. Determined if patient has had abdominal sur- ____ ____ ____ __________________________ gery, trauma, or diagnostic tests of the GI tract. ____ ____ __________________________ ____ ____ ____ __________________________ 5. Assessed if patient has had recent weight changes or intolerance to diet. ____ ____ ____ __________________________ ____ ____ __________________________ 6. Assessed for indications of GI alterations. ____ ____ __________________________ ____ ____ __________________________ 7. Determined if patient takes antiinflammatory ____ ____ __________________________ medications or antibiotic. ____ ____ __________________________ 8. Reviewed family history of cancer, kidney dis- ____ ____ __________________________ ease, alcoholism, hypertension, or heart disease. 9. Reviewed patient’s history for risks of HBV exposure. PLANNING ____ 1. Identified expected outcomes. 2. Anticipated teaching topics including warning ____ signs of colorectal cancer. ____ 3. Performed hand hygiene, gathered necessary supplies. MPLEMENTATION ____ 1. Prepared patient for abdominal assessment: ____ ____ a. Asked if patient needs to empty bladder or ____ defecate. ____ b. Kept patient’s upper chest and legs draped. ____ c. Ensured that room was warm. ____ d. Positioned patient properly. e. Exposed area from just above the xiphoid process down to the symphysis pubis. f. Maintained conversation during assessment except during auscultation, explained steps calmly and slowly. g. Asked patient to point to tender areas. 54 Copyright © 2018 by Elsevier Inc. All rights reserved.
2. Performed abdominal assessment: S U NP Comments a. Identified landmarks dividing abdominal ____ ____ ____ __________________________ region into quadrants. ____ ____ ____ __________________________ b. Inspected skin of abdomen’s surface for color, ____ ____ ____ __________________________ scars, venous patterns, rashes, lesions, stretch ____ ____ ____ __________________________ marks, and artificial openings; observed le- ____ ____ ____ __________________________ sions for characteristics described in skill 6.1. ____ ____ ____ __________________________ ____ ____ ____ __________________________ c. Asked if patient self-administers injections if ____ ____ ____ __________________________ bruising was noted. ____ ____ ____ __________________________ d. Inspected contour, symmetry, and surface motion of the abdomen; noted masses, bulg- ing, or distention. e. Noted if any distention was generalized, looked for flanks on each side. f. Measured size of abdominal girth if you sus- pected distention, used the marking pen to indicate where tape measure was applied. g. Turned off suction connected to an NG or NI tube momentarily. h. Auscultated bowel sounds appropriately, asked patient not to talk, listened at least 5 minutes before describing sounds as absent. i. Auscultated for vascular sounds with bell of stethoscope over the epigastric region and each quadrant. j. Peaocshitioofnethdepfaotuiernqt uaapdprraonptrsi,atneolyte, dpearrceuassseodf ____ ____ ____ __________________________ tympany and dullness. ____ ____ ____ __________________________ ____ ____ ____ __________________________ k. Asked patient if abdomen feels unusually tight, determined if this was a recent devel- ____ ____ ____ __________________________ opment. ____ ____ ____ __________________________ ____ ____ ____ __________________________ l. Positioned patient appropriately, percussed over each CVA along scapular lines, noted if patient experienced pain. m. Lightly palpated over each quadrant, palpat- ed painful areas last. (1) Noted muscular resistance, distention, ten- derness, and superficial masses; observed patient’s face for signs of discomfort. (2) Noted if abdomen was firm or soft to touch. n. Palpated for a smooth round mass below um- bilicus and above symphysis pubis, asked if patient had sensation of needing to void. Copyright © 2018 by Elsevier Inc. All rights reserved. 55
sS Uu NP Comments o. Noted size, location, shape, consistencyy, ten- derness, mobilityy, and texture of any masses palpated. ____ ____ ____ __________________________ p. Pressed one hand slowly into tender areas and released quicklyy, noted if pain was ag- gravated. ____ ____ ____ __________________________ EVALUATTIION 1.. Compared assessment findings with previous assessment characteristics to identify changes. ____ ____ ____ __________________________ 2.. Asked patient to describe signs and symptoms of colorectal cancer. ____ ____ ____ __________________________ 3.. Identified unexpected outcomes.. ____ ____ ____ __________________________ RECORDING AND REPORTING 1.. Documented appearance of abdomen, quality of bowel sounds, presence of distention, ab- dominal circumference, and presence and loca- ____ ____ ____ __________________________ tion of tenderness in appropriate record. 2.. Documented evaluation of patient learning. ____ ____ ____ __________________________ 3.. Recorded patient'’s ability to void and def- ____ ____ ____ __________________________ ecate, included description of output. 4.. Reported serious abnormall findings to nurse ____ ____ ____ __________________________ in charge and health care provider. 56 Copyright ©© 2018 by Elsevier Inc. All rights reserved.
Studen_t ____________________________________________________________________________ Date____________________________________ Instructorr _________________________________________________________________________ Date ___________________________________ PPEERRFFOORRMMAANNCCEE CCHHEECCKKLLIISSTT SSKKIILLLL 66..66 GENITALIA AND RECTUM ASSESSMENT sS uU NP Comments ASSESSMENTT 1.. Assessed female patient: a. Determined if patient has symptoms of vagi- nall ddiischarge, painful or swollen perianal tis- sue, or genital lesions. ____ ____ ____ __________________________ b. Determined if patient has symptoms or his- tory of genitourinary problems. ____ ____ ____ __________________________ c. Asked if patient has had signs of bleeding outsiidde of normal menstruation or after men- opaussee or has had unusual vaginal discharge. ____ ____ ____ __________________________ d. Determined if patient has received HPVV ____ ____ ____ __________________________ vacciinne. e. Determined if patient has history of HPVV, firrst pregnancy before age 117, smoking, obe- sityy, diet low in fruits and vvegetables, or has ____ ____ ____ __________________________ had mmultiple full-term pregnancies. f. Determined if patient is older than 63; is oobbeese; has historryy of ovarian dysfunction, bbrreast or eendometrial cancer, or endometrio- siss;; has family history of rreproductive cancer; has historryy of infertility or nulliparity; or uses estrooggen as horrmoonne replacement therapy. ____ ____ ____ __________________________ g. Determined if patient is postmenopausal, obese, orr infertile; had early menarche or late menopause; has historryy of hypertension, ddiiaabetes, ggaallllbbladder disease, or polycystic ovarryy ddiisease; has family history of endome- trial,, breast,, or colon cancer; or has history of ____ ____ ____ __________________________ estrogen-rrelated exposure. h. Determined patient'’s knowledge of risk factors aand signs of gynecological cancers. ____ ____ ____ __________________________ 2.. Assessed male patient: ____ ____ ____ __________________________ a. Reviewed normal elimination pattern. bb.. AiAnssgkk,,eegddeniiffitppaaalttliieeesnniott nhhsaa,ssonnrooutteereddthppreeannliildleeisppcaahiinanroogrre.sswweellll- ____ ____ ____ __________________________ c. Determined if patient has noted heaviness or paiinless enlargement or irregular lumps of ____ ____ ____ __________________________ testis.. Copyright ©© 201188 by Elsevier Inc.. All rights reserved. 5577
sS Uu NP Comments d. Determinedifpatientrreportedany enlargement of inguinal area; assessed if any enlargement was intermittent, associated with straining, and painful; assessed whethher coughing, lift- ing, or straining at stool causes pain. ____ ____ ____ __________________________ e. Asked if patient has experienced weak or in- terrupted urine flow, difficulty with urinat- ing, polyuria, nocturia, hematuria, or dysuria; determined if patient has continuing pain in lower back, pelvis, or upper thighs. ____ ____ ____ __________________________ f. Assessed patient'’s knowledge of risk factors and signs of prostate and testicular cancer. ____ ____ ____ __________________________ 3.. Assessed in all patients: a. Determined whether patient has experienced rectal bleeding or pain, black or tarry stools, ____ ____ ____ __________________________ or change in bowel habits. b. Determined whether patient has personal or family history of colorectal cancer, polyps, or chronic inflammatory bowel disease, asked ____ ____ ____ __________________________ if patient is over age 50. c.. Inquired about dietary habits. ____ ____ ____ __________________________ d. Determined if patient is obese, is physically inactive, smokes, has type 2 diabetes, or con- ____ ____ ____ __________________________ sumes alcohol. e. Assessed medication hhistory for use of laxa- ____ ____ ____ __________________________ tives or cathartic medications. f. Assessed for use of codeine or iron prepara- ____ ____ ____ __________________________ tions.. g. Assessed patient'’s knowledge of risks and ____ ____ ____ __________________________ signs of colorectal cancer. PPLLAANNNNIINNGG ____ ____ ____ __________________________ 1.. Identified expected outcomes. 2.. Anticipated teaching topics including warning ____ ____ ____ __________________________ signs of colorectal cancer. 3.. Performed hand hygiene, prepared necessary ____ ____ ____ __________________________ supplies. IIMMPPLLEEMMEENNTTAATTIIOONN 1.. Prepared patient for assessment: a. Asked if patient needs to empty bladder or a. dAesfkeecdateif.. patient needs to empty bladder or ____ ____ ____ __________________________ b. Kept patient'’s upper chest and legs draped, ____ ____ ____ __________________________ kept room warm. ____ ____ ____ __________________________ ____ ____ ____ __________________________ c. Positioned patient appropriatelyy. d. Applied clean gloves.. 58 Copyright ©© 2018 by Elsevier Inc. All rights reserved.
sS uU NP Comments 2.. Performed female genitalia examination: a. Exposed perineal area, repositioned sheet as needed.. ____ ____ ____ __________________________ b. Inspected surface characteristics of peri- neum; rretracted llabia majora; observed for iinflammation,, edema, lesions, or lacerations; noted iif therree was any discharge. ____ ____ ____ __________________________ 3.. Performed male genitalia examination: a. Exposed perineal area, observed for rashes, excoriations, orr lesions. ____ ____ ____ __________________________ b. Inspected and palpated all penile surfaces. ____ ____ ____ __________________________ c. Inspected and palpated testicular surfaces. ____ ____ ____ __________________________ d. Palpated testes, asked if patient experiences tenderneess wwith palpation.. ____ ____ ____ __________________________ 4.. Assessed rectum:: a. Positioned patient appropriatelyy. ____ ____ ____ __________________________ b. VViewed perianal and sacrococcygeal areas by retracting bbuuttttoocks using nondominant ____ ____ ____ __________________________ hhaanndd.. c. Inspected anal tissue for skin characteristics, lesions, external hemorrhoids, ulcers, inflam- ____ ____ ____ __________________________ mattiion,, rashes,, and excoriation.. 5.. Removed and discarded gloves, discarded dis- posablee supplies, helped patient to comfort- ____ ____ ____ __________________________ able ppoossition, performed hand hygiene. EEVVAALLUUAATTIIOONN 1.. Compared assessment findings with previous assessment characteristics to identify changes. ____ ____ ____ __________________________ 2.. Asked patient to describe signs and symptoms ____ ____ ____ __________________________ of appropriate cancers.. 3.. Asked patient to identify guidelines for HPV ____ ____ ____ __________________________ vvaacccination. 4.. Identiified unexpected outcomes. ____ ____ ____ __________________________ RREECCOORRDDIINNGG AANNDD RREEPPOORRTTIINNGG ____ ____ ____ __________________________ 1.. Documented results of assessment in appropri- ate record.. 2.. Recorded patient'’s ability to void, including ____ ____ ____ __________________________ ddeessccrriippttiioonn ooff oouuttppuutt.. ____ ____ ____ __________________________ 3.. Documented evaluation of patient learning. 4.. Reported abnormalities to nurse in charge and ____ ____ ____ __________________________ health care provideerr. Coppyyrriight ©© 201188 by Elsevier Inc.. AAll rightss reserved. 5599
SSttuuddeenntt______________________________________________________________________________ Date____________________________________ Instructtoorr_________________________________________________________________________ _ DDaattee ____________________________________ PPEERRFFOORRMMAANNCCEE CCHHEECCKKLLIISSTT SSKKIILLLL 66..77 MUSCULOSKELETTAL AND NEUROLOGICAL ASSESSMENT sS uU NP Comments AASSESSMENTT 11.. Revviiewed ppaattiient history for alcohol intake off morree than two drinks per day; inadequate iinttaake of proteiin, viitaamin D, or calcium; thin and light body frame; ffamily history of osteo- poorroossiiss;; whittee or Asian ancestrryy;; sedentary lliifestyle; lloong-tterrmm use of cceerrttaaiin medications; ____ ____ ____ __________________________ cerrttaaiinn medical conditions. 22.. Detteerrmmiined iiff patient hass been scrreened for os- tteeooppoorroossiiss.. ____ ____ ____ __________________________ 33.. AAsskkedd patientt tto descrriibee history of alterattiion iinn bone, muscllee,, or jjoint functtiion and location ____ ____ ____ __________________________ off alterraattiioonn.. 44.. AAsssseesssseedd naturre andd extentt off patient'’s muscu- loskelettaall paiin,, asked if walking affects report- ed lower extrremity pain or cramping, assessed distanccee walked and pain beforre, during, and ____ ____ ____ __________________________ after acttiivviityy.. 55.. AAsssseesssseedd forr hheeiight andd weight, noted if there ____ ____ ____ __________________________ iiss a ddeeccrreeaassee in women olderr than 50.. 66.. Deterrmmiinneedd iiff patiienntt usess analgeessiiccss,, antipsy- chhoottiics, annttiiddeepprreesssanttss, nervvous system stim- ____ ____ ____ __________________________ ulanttss, or recreatiional drugs. 77.. DDeetteerrmmined iiff ppaattiient hadd recent hhiistory of sseeiizzures or ccoonnvvuullssiions; ccllaarriified sequence of evveennttss; cchhaarracter of any ssyymmpttoms; and rela- ____ ____ ____ __________________________ ttiioonship to time of dayy, fatigguue, or stress. 88.. Screeenneedd patienntt for headache, tremorss,, diz- zinessss,, verttiiggoo,, numbness or tingling, visual chaannggeess,, weakness, pain, or changes in speech. ____ ____ ____ __________________________ 99.. Discussed withh sspoouussee,, family mmeemmberr, or ____ ____ ____ __________________________ friends any recentt changes in behavviioorr. 1100.. Assesssseedd patiienntt for history of changgee in vi- ____ ____ ____ __________________________ sion, hearing, smell, taste, or touch. 1111.. RReevviieewweedd hhiissttoorryy ffoorr ddrruugg ttooxxiicciittyy,, sseerriioouuss iinfecttiion, metabolic disturbances, heart fail- uurre, and ssevveerre anemia if patient displays sud- ____ ____ ____ __________________________ denn acute ccoonnffuussiion.. 60 Copyright ©© 2018 by Elsevier Inc. All rights reserved.
sS uU NP Comments 12.. Reviewed history for head or spinal cord in- jjuurryy, meningitis,, congenital anomalies, neuro- logicc disease,, or ppssychiatric counseling.. ____ ____ ____ __________________________ PPLLAANNNNIINNGG ____ ____ ____ __________________________ 1. Identified expected outcomes. 2. Performed hand hygiene, gathered necessary supplies. ____ ____ ____ __________________________ IIMMPPLLEEMMEENNTTAATTIIOONN 1. Prepared patient for assessment: a. Integrated musculoskeletal and neurologic assessments during other portions of assess- ment or care.. ____ ____ ____ __________________________ b. Planned time forr short rest periods during assessment. ____ ____ ____ __________________________ 2. Assessed musculoskeletal system: a. Observed ability to use arms and hands for ____ ____ ____ __________________________ grasping objects.. b. Assessed muscle strength of upper extremi- ties by applying grradual incrrease in pressure to muscle group.. ____ ____ ____ __________________________ c. Assessed hand grasp strength appropriatelyy. ____ ____ ____ __________________________ d. Asked patient to maintain pressure against re- sistance on arm orr leg, compared strength of symmetrical mmuusscle groups, noted weakness. ____ ____ ____ __________________________ e. Exposed muscles and joints, observed body ____ ____ ____ __________________________ alignment in different positions. f. Inspected gait as patient walked, had patient ____ ____ ____ __________________________ use assistive devices if appropriate. g. Performed the Get Up and Go Test. ____ ____ ____ __________________________ h. Stood behind patient; observed postural aalignment; looked sideways at cervical, tho- ____ ____ ____ __________________________ racic,, and luumbar curves. i. Made a general observation of extremities. ____ ____ ____ __________________________ j. Palpated bones, joints, and surrounding tis- sue iin iinnvvoolved areas; noted heat, tenderness, ____ ____ ____ __________________________ edema, or resistance to pressure. k. Asked patient to put major joint through its full ROM, observed equality of active and pfualslsiRvOe mMo, toiobnseinrvseadmeeqbuoadliytypaorftsa. ctive and ____ ____ ____ __________________________ 1l. Palpated joint for swelling, stiffness, tender- ____ ____ ____ __________________________ ness, and heat; noted any redness. m. Assessed muscle tone in major muscle ____ ____ ____ __________________________ groups.. Coppyyright ©© 201188 by Elsevier Inc.. All rights reserved.. 61
sS Uu NP Comments 3.. Performmeed neurologic assessment: a. Assessed LOC and orientation. ____ ____ ____ __________________________ b. Asssessed CNs.. (1) Assessed EOM for CNs III, IV, and VI. ____ ____ ____ __________________________ (2) Applied lightt sensation with cotton ball ____ ____ ____ __________________________ to symmetrical areas of the face. (3)) Had patient frown, smile, puff cheeks, and raise eyebrows for CN VII, noted symmetry. ____ ____ ____ __________________________ ((44)) Had patient speak and swallow for CNs IX and X, checked midline uvula and symmetrriical rise of uvula and soft palate, ____ ____ ____ __________________________ elicited gag reflex. c.. Assessed extremittiiees for sensation, performed sensory test with patient'’s eyes closed. (1) Asked patient to indicate when sharp or dull sensation was felt as sharp and blunt ends of tongue blade were alter- ____ ____ ____ __________________________ nately applied to symmetrical areas. (2) Applied light wisp of cotton in symmetri- ____ ____ ____ __________________________ cal areas. (3) Grrasped finger or ttoe, alternated mov- ing up and down, asked patient to state ____ ____ ____ __________________________ whether digit was up or down. d.. Assessed motorr and cerebellar function. (1) Had patient walk across the room, tumrn, and come back, noted use of assistive de- ____ ____ ____ __________________________ vices.. (2) Had patient stand straight first with eyes open and then closed, observed for ____ ____ ____ __________________________ swaying. e. Assessed DTRs.. ((11)) Determmiinneed necessity to monitor DTRs. ____ ____ ____ __________________________ ((22)) Compared sides for each reflex tested ____ ____ ____ __________________________ and assigned a grade. ((33)) Palpated the patellar tendon just below the patella, tapped pointed end of reflex ____ ____ ____ __________________________ hammer on the tendon.. ((44)) Stroked lateral aspect of the sole from ____ ____ ____ __________________________ the heel to the ball of the foot. ((55)) Noted prresence of Babinski'’s reflex. ____ ____ ____ __________________________ 44. DDisposed of supplies, performed hand hygiene. ____ ____ ____ __________________________ 62 Copyright ©© 2018 by Elsevier Inc. All rights reserved.
sS uU NP Comments EVALUATTION 1. Compared muscle strength and ROM with previous physical assessment. ____ ____ ____ __________________________ 2. Compared neurologic status with previous assessment. ____ ____ ____ __________________________ 3. Evaluated level of patient discomfort on the appropriate pain scale. ____ ____ ____ __________________________ 4.. Identified unexpected outcomes. ____ ____ ____ __________________________ RECORDING AND REPORTING ____ ____ ____ __________________________ 1. Documented posture, gait, muscle strength, and ROM in appropriate record. 2. Documented LOC, orientation, papillary re- sponse, sensation, and reflex response in appro- priate record.. ____ ____ ____ __________________________ 3.. Documented evaluation of patient learning. ____ ____ ____ __________________________ 4. Reported to nurse in charge or health care pro- vider acute pain, sudden muscle weakness, change in LOC, or change in size or pupillary reaction.. ____ ____ ____ __________________________ Coppyyright ©© 201188 by Elsevier Inc.. All rights reserved. 63
SSttuuddeenntt____________________________________________________________________________ Date____________________________________ Inssttrruuccttoorr__________________________________________________________________________ _ DDaattee____________________________________ PPEERRFFOORRMMAANNCCEE CCHHEECCKKLLIISSTT PPRROOCCEEDDUURRAALL GGUUIIDDEELLIINNEE 66..11 MONITORING INTAKE AND OUTPUT sS uU NP Comments PROCEDURAL STEPS 11.. Iddeennttiiffiiedd ppattients with conddiitions that in- ccrreeaassee fluuiidd loss.. ____ ____ ____ __________________________ 22.. IIddeennttiiffied ppaattiientss wwiithh iimpaired sswwaalllowing, unconsscciious patients, and patients with im- ppaaiired mobbiility. ____ ____ ____ __________________________ 33.. Iddeennttiiffiiedd patients onn medicattiionn that influ- encess fflluuid bbaallanccee.. ____ ____ ____ __________________________ 44.. Assesssseedd signs and symptoms of dehydration aand ffluuiid overload. ____ ____ ____ __________________________ 55.. WWeighedd patients daily ussiinngg same scale, same tiimmee of dayy, and comparable clothing. ____ ____ ____ __________________________ 66.. MMoonniittoorredd laborattoorryy reports including urine speecciific ggrraavvity and Hct. ____ ____ ____ __________________________ 77.. Assesssseedd patient'’ss aand family'’s knowleddggee of ppurpose andd process of I&O measurement. ____ ____ ____ __________________________ 88.. Exxppllaaiined too ppaattient and family the reason ____ ____ ____ __________________________ I&O aarre importaanntt.. 99.. Performed hand hyggiiennee.. ____ ____ ____ __________________________ 1100.. Meassuurreedd aand recorded all intaakke of fluid ____ ____ ____ __________________________ aappprroprriiateelyy.. 1111.. Instruucctted patient and ffaamily to call you or NAP to empty contents of uriinnal, uurine hhat, or com- mmoddee everryy tiimmee ppattient uses it; instructed them to monitorr iinnccoonttiinence, vvomiting, and exccessssiive ____ ____ ____ __________________________ ppeerrssppiiration and to report it to the nurse. 1122.. Informed ppaattiient andd familyy thatt drainage bbaagg and tube drraaiinage arre closely monitored, mmeasuurredd,, and recorded and who is responsi- ble, ensured grraadduuaattiion container was clearly ____ ____ ____ __________________________ mmaarrkkedd.. 1133.. AApppplliied cleaann gglloves; measured drainage as iinnddiicatedd; nnooted ccolor and characteristics; wwoorree mmaasskk,, eeyyee pprrootteeccttiioonn,, oorr ggoowwnn iiff nneeeeddeedd.. ____ ____ ____ __________________________ 1144.. RReemmoved ggllooves and disposed of them ____ ____ ____ __________________________ pprroperlyy,, ppeerrfformed hand hygiene.. 6644 Copyright ©© 2018 by Elsevier Inc. All rights reserved.
sS uU NP Comments 15. Noted I&O balance or imbalance, reported urine output less than 30 mL/hr or significant changes in daily weight.. ____ ____ ____ __________________________ 16. Documented on I&O form or electronic record. ____ ____ ____ __________________________ Copyright ©© 2018 by Elsevier Inc.. All rights reserved. 65
SSttuuddeenntt______________________________________________________________________________ Date____________________________________ Instrruccttoorr_________________________________________________________________________ _ DDaattee ____________________________________ PPEERRFFOORRMMAANNCCEE CCHHEECCKKLLIISSTT SSKKIILLLL 77..11 URINE SPECIMEN COLLECTION: MIDSTREAM (CLEAN-VOIDED) URINE; STERILE URINARY CATHETER sS uU NP Comments ASSESSMENT ____ ____ ____ __________________________ 1.. IIddeennttiiffiiedd ppaattiient uussiing twoo iidenttiifiers. ____ ____ ____ __________________________ 22.. AAsssseesssedd ppaattiientt'’s or family'’s understanding of purppoose of test and method of collection. ____ ____ ____ __________________________ ____ ____ ____ __________________________ 33.. AAsssseessssedd ppaattiientt'’s ability to assist with urine specciimen collection. ____ ____ ____ __________________________ 44.. AAsssseesssedd forr signs of UTII.. ____ ____ ____ __________________________ 55.. Referrred ttoo agencyy procedures for collecttiion ____ ____ ____ __________________________ methods. ____ ____ ____ __________________________ PLANNING ____ ____ ____ __________________________ 1.. IIddeennttiiffiied expectteedd oouuttccoommeess.. ____ ____ ____ __________________________ ____ ____ ____ __________________________ IMPLEMENTATTIION ____ ____ ____ __________________________ 1.. Perrffoorrmmeedd hhaanndd hhyyggiieene, checked labels and ____ ____ ____ __________________________ completed laboratory rreqquuisition for container. ____ ____ ____ __________________________ 22.. PPrroovviiddeedd pprriivvaaccyy,, aallowed mobile patient to collect specimen in bathroom. 33.. CCoolllleecctteedd clean-vvooiideedd urriinnee specimen:: aa.. Apppplliieedd clleeaann gloves, gavee patient supplies to cclleeaann perineum or assisted patient in cleansing perineum, removed and disposed off gloves. bb.. Oppeenneedd packkaaggee off commerrcciial specimen kkiitt ussiinngg aseptic technique. cc.. PPoourred aanttiisepttic solution over cotton balls iiff necessaryy. dd.. Oppeenned ssppecimen contaaiinneerr, maiintaiinned steril- iittyyoff innssiidde offccoonttaiinneerr, placed cap properlyy. e.. AAssssiistedd orr allowed patient to cleaannsse peri- neuumm and collect specimen, informed pa- tient aannttiiseptic would feel cold. ((11)) FFoorr mmaallee ppaattiieenntt:: ((aa)) Held ppeennis wwiitthh onee hhand, cleansed meatus properlyy, had patient retract foreskkiinn if necessaryy, returned fore- skkiinn when done. 66 Copyright ©© 2018 by Elsevier Inc. All rights reserved.
Ss uU NP Comments (b) RRinsed area and dried if agency pro- ____ ____ ____ __________________________ cceeddure indicates.. ____ ____ ____ __________________________ (c)) Had patient pass container through urine stream after patient initiated ____ ____ ____ __________________________ ssttrreeam.. ____ ____ ____ __________________________ ____ ____ ____ __________________________ (2) For female patient: ____ ____ ____ __________________________ (a) Spread labia minora with fingers of nondominant hand or had patient ____ ____ ____ __________________________ asssiisstt.. ____ ____ ____ __________________________ ____ ____ ____ __________________________ (b) CCleansed urethral area appropriatelyy, used freshh swab for each fold.. ____ ____ ____ __________________________ (c)) Rinsedd area and dried with cotton ____ ____ ____ __________________________ balll iff agency procedure indicates. ____ ____ ____ __________________________ (d)) Passed specimen container into ____ ____ ____ __________________________ urinee ssttrream after patient initiated ____ ____ ____ __________________________ strream.. ____ ____ ____ __________________________ ____ ____ ____ __________________________ f.. Removed specimen container before flow ____ ____ ____ __________________________ ssttoopped and bbeeffore releasing labia or penis, ____ ____ ____ __________________________ aassssissted with perssonal hygiene as appropri- aatte.. 67 g.. Replaced cap on container, touched only oouuttside. h.. CClleaned urine from exterior surface of con- tainneerr.. 44.. Collleeccted urine from indwelling urinary cathheter: a.. Explained use of needleless syringe and that ppaattient would not experience discomfort. b. Explained need to clamp catheter 10 to 15 minutes before obtaining specimen and that it could not bbe obbtained frrom ddrrainage bag. c. Applied clean gloves, clamped drainage tubbiinngg below withdrawal site. d.. Positioned patient properlyy, located port, cclleeansed port with disinfectant and allowed to dryy.. e.. Attached needleless Luer-Lok syringe to port aapprropriatelyy.. f.. WWithdrew appropriate amount for culture ffoorr rroouuttiinnee uurriinnaallyyssiiss.. g. TTransferred urine from syringe to appropri- aate conttaaiinneerr.. h.. Placed lid tightly on container. i.. Undclamped catheter, ensured urine was fflloowwiinngg ffrreeeellyy.. Coppyyrriightt ©© 201188 by Elsevier Inc.. AAll rights reserved..
sS uU NP Comments 5.. Secured label to conttaainerr, completeedd label ____ ____ ____ __________________________ properlyy. ____ ____ ____ __________________________ 6.. Disposed of soiled supplies, removed and dis- carded gloves, performed hand hygiene. ____ ____ ____ __________________________ 7.. Sent specimeenn and requisition to laboratoryy ____ ____ ____ __________________________ within 20 minutes, refrigerated specimen if necessaryy. ____ ____ ____ __________________________ EVALUATTIION ____ ____ ____ __________________________ 1.. Inspectedd clean-voided specimen for contam- ____ ____ ____ __________________________ ____ ____ ____ __________________________ ination. ____ ____ ____ __________________________ 2.. Evaluated patient'’s urine C&S report for bac- ____ ____ ____ __________________________ terial growth. ____ ____ ____ __________________________ 3.. OObserved uurrinary ddrraainage system to ensure it was intact and patent. 4.. Asked patient to explains steps in procedure. 5.. Identified unexpected outcomes. RECORDING AND REPORTING 1.. Recorded collection of specimen in appropri- ate log. 2.. Documented evaluation of patient learning. 3.. Reportedd anyy abnormal findings to health care providerr. 68 Copyright ©© 2018 by Elsevier Inc. All rights reserved.
Student______________________________________________________________________________ Date____________________________________ Instructor__________________________________________________________________________ _ DDatee____________________________________ PPEERRFFOORRMMAANNCCEE CCHHEECCKKLLIISSTT PPRROOCCEEDDUURRAALL GGUUIIDDEELLIINNEE 77..11 COLLECTING A TIMED SPECIMEN Ss Uu NP Comments PROCEDURAL STEPS ____ ____ ____ __________________________ 1. Identified patient using two identifiers, ccoommppaarreed identifiers wwithh patient'’s MAAR. ____ ____ ____ __________________________ 2. Explained reason for specimen collection, how ____ ____ ____ __________________________ ppaattiieenntt caannhheellpp, and that urine must bbe free of ____ ____ ____ __________________________ ccoonnttaammiinnaannttss.. ____ ____ ____ __________________________ 3. Placed collection container in bathroom, ____ ____ ____ __________________________ iinncclluuddeedd cann off iiccee iff iinnddiiccaated; poostedd signs ____ ____ ____ __________________________ rreminding ooff timed urine ccoollection; ensured ppeerrssoonnnneell inn rreceiving aarrea collected and ____ ____ ____ __________________________ saved uurriinne iff ppaatient left unit.. ____ ____ ____ __________________________ 4. HHad patient drink two to four glasses of water ____ ____ ____ __________________________ aabboouutt 3300 minuttes bbeeffoorree times off collection.. 55. Performed hand hygiene, applied clean gglloovveess, discarrded firrsstt specimmeenn as test bbeeggan, iinnddiiccaatteedd ttiimme tteest bbeegan oon rrequisition, en- ssuurred ppaattiieenntt bbeeggaan tteest wwitthh eemmpty blaaddddeerr, bbeeggaann collleeccttiinngg alll urriinnee for designatteedd time. 6. Measurreedd volume of each voiding if I&O was too bbee recorrddeedd,, placed alll urine in labeled speecciimmeenn bboottttlleess wwiitthh appropriaatte additives. 7. Kept specimen bottle in refrigerator or ice in bbaatthhrroooomm tto prrevent ddeeccoomposition of urine unnlleesss innsstrructed ootherrwwise. 8. Encouraged patient to drink two glasses of wwaatteerr 11 hhoour bbeeffoorree ccoolllleection ended and eemmppty bllaadddderr durriinngg last 1155 minutes of ccoolllleeccttion perriioodd.. 9. Performed hand hygiene, applied clean gglloovveess, ccollected finnaall specimen, labeled speci- mmeenn apprroprriiaatteellyy,, aattttached requisition, sent too laborraattoorryy,, rremoved gloves, performed hhaanndd hhyyggiiene.. 10. Removed signs, informed patient specimen ccoolllleeccttiioonn ppeerriioodd wwaass ccoommpplleettee.. Cooppyyrigghtt ©© 201188 by Elsevier Inc.. AAll rights reserved. 69
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