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    Rubrics: Physical Assessment: Instruction: Check Appropriate Level of Competence

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    Lorraine Cayamanda
    The document provides a rubric for assessing nursing students' competence in performing a physical assessment of patients. It lists 14 procedures involved in the physical assessment and provides a 4-point scale to rate students' confidence, organization, and comprehension of each step. The rubric also provides detailed instructions on assessing the 15 cranial nerves as part of the physical examination.

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    Rubrics: Physical Assessment: Instruction: Check Appropriate Level of Competence

    Uploaded by

    Lorraine Cayamanda
    48 views7 pages
    The document provides a rubric for assessing nursing students' competence in performing a physical assessment of patients. It lists 14 procedures involved in the physical assessment and provides a 4-point scale to rate students' confidence, organization, and comprehension of each step. The rubric also provides detailed instructions on assessing the 15 cranial nerves as part of the physical examination.

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    i Cranial Nerves

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    The document provides a rubric for assessing nursing students' competence in performing a physical assessment of patients. It lists 14 procedures involved in the physical assessment and provides a 4-point scale to rate students' confidence, organization, and comprehension of each step. The rubric also provides detailed instructions on assessing the 15 cranial nerves as part of the physical examination.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    48 views7 pages

    Rubrics: Physical Assessment: Instruction: Check Appropriate Level of Competence

    Uploaded by

    Lorraine Cayamanda
    The document provides a rubric for assessing nursing students' competence in performing a physical assessment of patients. It lists 14 procedures involved in the physical assessment and provides a 4-point scale to rate students' confidence, organization, and comprehension of each step. The rubric also provides detailed instructions on assessing the 15 cranial nerves as part of the physical examination.

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    San Pablo Colleges

    Colleges of Nursing
    San Pablo City

    Rubrics: Physical Assessment

    Instruction: Check appropriate level of competence.

    With little Somewhat Confident,


    No confidence,
    confidence, confident, organized and
    disorganized,
    somewhat organized and with complete
    shows no
    organized, with sufficient comprehension
    comprehension
    Procedure of the steps
    shows little comprehension of the steps.
    comprehension of the steps
    of the steps
    1 pt. 2 pts. 3 pts. 4 pts.
    1. Perform hand washing.

    2. Gather all equipment


    needed.
     Weighing scale
     Gloves
     Tape
     Tongue blades
     Percussion hammer
     Otoscope
     Tuning fork
     Tape measure
     Snellen chart
     Ophthalmoscope
     Water-soluble pads
     Water soluble lubricant
     Tissue
     Cotton-tipped applicator

    3. Identify client and explain the


    procedure.

    4. Instruct the client to void


    before doing the physical
    examination.

    5. Ensure the privacy of the


    client.

    6. Assist the patient to undress


    and put in a gown.

    7. Measure the patient’s height


    and weight and take the
    vital sign.
    With little Somewhat Confident,
    No confidence,
    confidence, confident, organized and
    disorganized,
    somewhat organized and with complete
    shows no
    organized, with sufficient comprehension
    comprehension
    Procedure of the steps
    shows little comprehension of the steps.
    comprehension of the steps
    of the steps
    1 pt. 2 pts. 3 pts. 4 pts.
    8. Observe the client’s:
     General appearance
     Skin color and obvious
    lesions
     Dress, grooming and
    personal hygiene
     Posture
     Gait
     Motor activity
     Mood and effect
    9. Note body and breathe odor
    in relation to activity level.
    10. Observe for sign of distress,
    posture and facial
    expression
    11. Asses the appropriateness
    of client’s response,
    relevance and organization
    of thought.
    12. Listen for quality, quantity
    and organization of speech.
    13. Assist the client in assuming
    a position appropriate for
    examination. Drape the
    client according to the area
    of examination.
    14. Conduct the physical
    examination starting from
    head and ending with the
    toe.
    15. CRANIAL NERVE
    ASSESSMENT

    CN I- OLFACTORY NERVE
     Place the client in a
    comfortable sitting
    position.
     Ask the client to clear
    his nose to remove any
    mucus. Then ask patient
    to inhale/exhale thru the
    other, assuring it’s
    unobstructed.
     Screen for problems w/
    sense of smell using
    alcohol pad. Ask patient
    to close eyes & present
    alcohol pad slowly up
    towards the nostril being
    tested (checking each
    separately).
    No confidence, With little Somewhat Confident,
    disorganized, confidence, confident, organized and
    shows no somewhat organized and with complete
    comprehension organized, with sufficient comprehension
    Procedure of the steps shows little comprehension of the steps.
    comprehension of the steps
    of the steps

    1 pt. 2 pts. 3 pts. 4 pts.


     Present patient with a
    variety of smelling aids
    (onion, coffee, flowers,
    etc.), in order to detect
    malfunctioning of CN 1

    CN II- OPTIC NERVE


     Using hand held card
    (held @ 14 inches) or
    Snellen wall chart,
    assess each eye
    separately. Allow patient
    to wear glasses. Direct
    patient to read aloud line
    with smallest lettering
    that they’re able to see.
    Assess visual fields.
    Face patient, roughly 1-
    2 ft apart, noses @
    same level. Close your
    R eye, while patient
    closes their L. Keep
    other eyes open & look
    directly at one another.
    Move your L arm out &
    away, keeping it ~
    equidistant from the 2 of
    you. A raised index
    finger should be just
    outside your field of
    vision. Wiggle finger and
    bring it in towards your
    noses. You should both
    be able to detect it @
    same time.
     Assess near vision; view
    the retina and the optic
    disc of the eye with an
    ophthalmoscope.

    CN III- OCULOMOTOR
    NERVE, CN IV- TROCHLEAR
    NERVE, CN VI- ABDUCENS
     Inspect the margins of
    the eyes.
     Assess extra ocular
    movements - Patient
    doesn’t move head,
    following your finger w/
    their eyes as you trace
    out letter “H”.
    Alternatively, direct them
    No confidence, With little Somewhat Confident,
    disorganized, confidence, confident, organized and
    shows no somewhat organized and with complete
    comprehension organized, with sufficient comprehension
    Procedure of the steps shows little comprehension of the steps.
    comprehension of the steps
    of the steps

    1 pt. 2 pts. 3 pts. 4 pts.

    to follow finger with their


    eyes as you trace large
    rectangle
     Test for the six cardinal
    points of gaze.
     Assess pupillary
    response to light and
    accommodation in both
    eyes.

    CN V- TRIGEMINAL NERVE
     Ask the client to look
    upward, lightly touch the
    lateral sclera to elicit
    blink reflex.
     Ask the client to close
    his eyes. Touch the
    forehead lightly with
    cotton to test light
    sensation in three areas
    (ophthalmic, maxillary,
    mandibular)
     Test deep sensation by
    touching the forehead
    with a pin or paper clip.

    CN VII- FACIAL NERVE


     Observe facial
    symmetry.
     Ask the client to smile,
    frown, wrinkle the
    forehead, puff cheeks,
    show teeth, purse lips,
    raise eyebrows and
    close eyes tightly.
     Ask the client to identify
    different tastes by
    placing different food
    granules (e.g, salt,
    coffee, sugar) on the tip
    and sides of the tongue.

    CN VIII- AUDITORY or
    ACOUSTIC NERVE
     Crude test hearing – rub
    fingers next to the client’s
    ears one at a time,
    whisper words then ask
    client to repeat them.
     Assess the client’s ability
    to hear the vibrations of
    With little Somewhat Confident,
    No confidence,
    confidence, confident, organized and
    disorganized,
    somewhat organized and with complete
    shows no
    organized, with sufficient comprehension
    comprehension
    Procedure shows little comprehension of the steps.
    of the steps
    comprehension of the steps
    of the steps

    1 pt. 2 pts. 3 pts. 4 pts.

    the tuning fork. Strike a


    512 Hz tuning fork and
    place it just beside the
    ear and ask client to raise
    his hand once he cannot
    hear the vibrations
    anymore, time the
    procedure then repeat in
    the other ear.
     Perform the Webber Test
    – strike the tuning fork
    and place it in the midline
    of the skull (frontal area),
    ask client to raise his
    hand once he cannot
    hear the vibrations
    anymore.
    Perform the Rinne Test
    – strike the tuning fork
    and place it on the
    client’s mastoid bone,
    ask client to raise hand
    one he cannot hear the
    vibrations anymore, then
    move the tuning fork
    near the client’s ear and
    ask to raise his hand if
    the vibrations cannot be
    heard anymore. Time
    both procedures (bone
    and air conduction).
    Repeat in the other ear.

    CN IX-
    GLOSSOPHARYNGEAL
    NERVE
     Ask the client to open
    his mouth and check the
    uvula if it is midline. Ask
    client to stick out his
    tongue and say “Ahhh”.
    Use a tongue depressor
    if the uvula cannot be
    viewed.
     Ask the client to move
    his tongue form side to
    side, up and down.
     Ask the client to identify
    the taste applied on the
    posterior part of his
    tongue.
    With little Somewhat Confident,
    No confidence,
    confidence, confident, organized and
    disorganized,
    somewhat organized and with complete
    shows no
    organized, with sufficient comprehension
    comprehension
    Procedure shows little comprehension of the steps.
    of the steps
    comprehension of the steps
    of the steps

    1 pt. 2 pts. 3 pts. 4 pts.


    CN X - VAGUS NERVE
     Assess the client’s
    speech for hoarseness.
     Provoke the gag reflex
    (CNs IX and X)

    CN XII – HYPOGLOSSAL
    NERVE
     Ask the client to
    protrude his tongue,
    move it to each side
    against resistance from
    the tongue depressor,
    then put it back into his
    mouth.
     Assess the tone and
    strength of all muscle
    groups.

    CN XI- ACCESORY NERVE


     Ask the client to raise
    his shoulders against
    resistance to assess the
    trapezius muscle.
    Repeat with the other
    side.

     Ask the client to turn his


    head against resistance,
    first to the right then and
    to the left.

    GRADING SYSTEM REMARKS


    95% - 100% Excellent 80% - 84% Satisfactory DRP – Dropped
    90% – 94% Superior 75% - 79% Passing INC – Incomplete
    85% - 89% Very 74% and below Failed F =- Failed
    Satisfactory

    Score: _________/__________ x 50 + 50 = ___________

    COMMENTS:
    __________________________________________________________________________________

    ________________________
    Signature over Printed Name

    Evaluated by:

    ________________________
    Clinical Instructor

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