You will perform a history of a peripheral vascular problem that your instructor has provided you or one that you have exp

Student Name: ______________________________________

Date: _________________

Points Possible

Points Earned

Comments

Pre-Procedure Steps

Knocks

1

Washes hands

1

Identifies the client with 2 identifiers

1

Provides privacy

1

Explains procedure

0.5

General Survey (Appearance & Mental Status)

Assess level of consciousness and orientation to person, place and time

0.5

Assess quality and appropriateness of speech

0.5

Inspect posture & general hygiene

0.5

HEENT (Head, Ears, Eyes, Nose, Throat) and Neck

Inspect head for bumps, lesions, hair distribution ,and parasites

0.5

Inspect face for sensation (CN V [trigeminal]) and movement (VII [facial])

2

Inspect external eyes for redness & discharge. Inspect pupil size and PERRLA (CN III [oculomotor])

3

Inspect extraocular muscle movements (CN III [oculomotor] IV [trochlear, VI [abducens)

3

Perform confrontation test (CN II [optic])

2

Inspect mouth – mucous membranes & general dentition condition, tongue midline, say “ah”-uvula midline, observe swallow (CN lX [glossopharyngeal], X [vagus], & XII [hypoglossal])

4

Inspect nose for discharge, nasal patency, & deviations in shape

2

Inspect ears for cerumen or other discharge in external canal, lesions & gross hearing (rub fingers together by ear – CN VIII [acoustic])

2

Assess CN XI (shoulder shrug & turn head against resistance)

2

Palpate the following lymph nodes: submental, submandibular, tonsillar, preauricular, postauricular, anterior cervical, posterior cervical, occipital, and supraclavicular

4.5

Thorax, Lung, and Back Assessment

Inspect shape of thorax with comparison of anteroposterior to transverse diameters

1

Assess respiratory rate, rhythm, depth, presence of accessory muscle use or cough

1

Inspect spinal alignment

2

Percuss for costovertebral angle tenderness

2

Palpate for thoracic expansion

2

Palpate for tactile fremitus

2

Auscultate breath sounds anterior and posterior at least 8 places on each side and 2 places in the axillary region on each side (stethoscope on skin). Total of 20 places.

10

Heart and Central Vessels Assessment

Palpate carotid pulses (ONE AT A TIME)

1

Student Name: ______________________________________

Date: _________________

Points Possible

Points Earned

Comments

Auscultate each carotid artery for bruits

1

Auscultate heart sounds in the aortic, pulmonic, Erb’s point, tricuspid, & mitral areas (stethoscope on skin)

10

Gastrointestinal & Genitourinary Assessment

Inspect shape of abdomen

1

Auscultate bowel sounds in all 4 quadrants (stethoscope on skin)

4

Lightly palpate all 4 abdominal quadrants for distension or tenderness

4

Assess bowel & urinary habits, problems & last BM

1

Musculoskeletal, Neurologic, & Peripheral Vascular Assessment

Inspect and palpate extremities for edema, tenderness, temperature, deformities & lesions

1

Check capillary refill of fingers and toes

1

Inspect gait and balance (Romberg test)

2

Assess range of motion of neck, arms, & legs (at least 3 directions for each)

4

Assess strength in all extremities

4

Assess the following deep tendon reflexes: patellar, plantar, triceps, Achilles, biceps, & brachioradialis.

6

Locate and palpate radial, brachial, popliteal, posterior tibial, and dorsalis pedis pulses, assessing for symmetry and strength.

5

Post-Procedure Steps

Inquires if the client is comfortable

0.5

Student is professional and courteous with their communication

1

Ensures the client has their call light

1

Ensures client’s personal items are within reach (glasses, phone, etc.)

0.5

Washes hands

1

Total Points Earned

of 100 possible

The above named student has:

Passed this skill evaluation

Failed this skill evaluation and must remediate. Plan for remediation:

Student signature and date indicating agreement with remediation plan: _____________________________________

Instructor signature and date indicating agreement with remediation plan: ___________________________________