PA_Module 09 Card

Levels of Achievement

Criteria

Emerging

Competence

Proficiency

Mastery

Subjective

(4 Pts)

Missing components such as biographic data, medications, or allergies. Symptoms analysis is incomplete. May contain objective data.

Basic biographic data provided. Medications and allergies included. Symptoms analysis incomplete. Lacking detail. No objective data.

Basic biographic data provided. Included list of medications and allergies. Symptoms analysis: PQRSTU completed. Lacking detail. No objective data. Information is solely what “client” provided.

Basic biographic data provided. Included list of medications and allergies. Symptoms analysis: PQRSTU completed. Detailed. No objective data. Information is solely what “client” provided.

Points: 1

Points: 2

Points: 3

Points: 4

Objective

(4 Pts)

Missing components of assessment for particular system. May contain subjective data. May have signs of bias or explanation of findings. May have included words such as “normal”, “appropriate”,
“okay”, and “good”.

Includes all components of assessment for particular system. Lacks detail. Uses words such as “normal”, “appropriate”, or “good”. Contains all objective information. May have signs of bias or explanation of findings.

Includes all components of assessment for particular system. Avoided use of words such as “normal”, “appropriate”, or “good”. No bias or explanation for findings evident Contains all objective information

Includes all components of assessment for particular system. Detailed information provided. Avoided use of words such as “normal”, “appropriate”, or “good”. No bias or explanation for findings evident. All objective information

Points: 2

Actual or Potential Risk Factors

(2 pts)

Lists one to two actual or potential risk factors for the client based on the assessment findings with no description or reason for selection of them. Failure to provide any potential or actual risk factors will result in zero points for this criterion.

Brief description of one or two actual or potential risk factors for the client based on the assessment findings with description or reason for selection of them.

Limited description of two actual or potential risk factors for the client based on the assessment findings with description or reason for selection of them.

Comprehensive, detailed description of two actual or potential risk factors for the client based on the assessment findings with description or reason for selection of them.

Points: 0.5

Points: 1.5

Student Name: ______________________________________

Date: _________________

Points Possible

Points Earned

Comments

Knocks

Washes hands

Identifies the client with 2 identifiers

Provides privacy

Explains procedure

Identifies any issues that may impact client safety or personal safety

General Survey

Assess level of consciousness

Assess skin color

Thorax

Inspect shape of thorax with comparison of anteroposterior to transverse diameters

5

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

Palpate thoracic expansion

Palpate for tactile fremitus

Lungs

Auscultate breath sounds 8 places on anterior thorax (stethoscope on skin)

10

Auscultate breath sounds 8 places on posterior thorax (stethoscope on skin)

Auscultate breath sounds 2 places each in axillary area bilaterally (stethoscope on skin)

Carotid Artery

Palpate carotid pulses (One at a time)

Auscultate each carotid artery for bruits (have client hold exhale, and hold breath)

Heart

Palpate anterior thorax for heave or thrill

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

20

Post-Procedure Steps

Inquires if the client is comfortable

Student is professional and courteous with their communication

Ensures the client has their call light

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

Washes hands

Total Points Earned

of 100 possible

Student Name: ______________________________________
Date: _________________

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: ___________________________________