Student Name: Kim Knecht Simulation #____

5 Date: 10/29/2018

Clinical ✔ Lab Midterm Final

NURS 320C Clinical Evaluation Tool

1. Student demonstrates interview, inspection, palpation, percussion and auscultation techniques to perform an organized, basic head to toe
physical assessment.
2. Discriminate between normal and abnormal health assessment findings in all body systems of an individual patient.
3. Correlates assessment abnormalities to major pathological problems and patient recommendations.
4. Performs focused assessments based on subjective and objective data.
5. Implement appropriate strategies to assess mental status, pain, nutritional status, spiritual health, psychosocial wellbeing, and family
functioning based upon the patient situation and utilizing subjective data.
6. Recommend evidence-based health interventions to address basic assessment deviations.
7. Communicate patient care information using SBAR to the health care team

Check the box that matches the student performance in the rubric below for each objective.

Student assessment check green box. Peer assessment check blue box. Faculty assessment check yellow box.

Unsatisfactory/ Developing Proficient Distinguished

Beginning 2 3 4
1
Physical Assessment was Physical Assessment was Physical Assessment was Physical Assessment was
Head to Toe Assessment
1.

grossly incomplete. Student
did not use correct
inspection, palpation,
percussion and auscultation
techniques.
incomplete, lacked
organization and flow.
inspection, palpation,
percussion and auscultation
were used, but lacked depth
and understanding.
complete or nearly complete.
Assessment used correct
inspection, palpation,
percussion, and auscultation
techniques, but lacked flow
and understanding.
✔ ✔ ✔
completed with accuracy and
in the allotted time.
Assessment was organized
using correct inspection,
palpation, and auscultation
techniques. The nurse used
these techniques to gather
normal and abnormal
findings with flow and
professionalism.
 Unsatisfactory/
Beginning
1
Normal and abnormal health
Patient Findings
2.
assessment findings were
not discussed with the
patient or were limited in
discussion with the patient.
Nurse was unable to
Data
3.
Making Sense of the
correlate assessment
abnormalities to major
pathological problems and
patient recommendations.
Performs the wrong focused
Focused Assessment
4.
assessment or grossly
incomplete. Lacks
confidence, flow, and/or
timeliness.
Major components with
observation, auscultation, or
palpation are missed.
Focused assessment
occurred out of order.
Developing
2 3
Normal and abnormal health
assessment findings were
identified and discussed with
the patient. Nothing or very
little was done with this
information.
Nurse was able identify
abnormalities and major
pathological problems, but
was unable to identify any
related patient
recommendations.
Performs correct focused
assessment, but is
incomplete and/or lacks
timeliness. Major
components with
observation, auscultation, or
palpation are missed.
Focused assessment
occurred out of order.
Proficient
Normal and abnormal
assessment findings
identified and discussed with
the patient. Emphasis was
not placed on the focused
assessment findings and did
not make sense of the data.
✔ ✔ ✔
Nurse identifies
abnormalities and major
pathological problems, but
was unable to utilize
information to identify
correct patient
recommendations.
✔ ✔ ✔
Performs correct and timely
focused assessment based
upon the subjective and
objective data. Focused
assessment includes most of
the essential components
within observation,
auscultation, and palpation
requirements.
✔ ✔ ✔
Distinguished
4
Normal and abnormal health
assessment findings were
identified and discussed with
the patient. The nurse
completed the focused
findings and made sense of
the data that was found.
Nurse was able to correlate
assessment abnormalities to
major pathological problems
and patient
recommendations.
Performs correct, complete,
and timely focused
assessment based upon the
subjective and objective
data.
Focused assessment includes
all essential components
within the observation,
auscultation, and palpation
requirements.
Focused assessment
occurred after patient’s vital
signs were taken.
 Unsatisfactory/
Beginning
1
Gathering subjective data
Subjective Data
5.
was very limited, awkward,
and lacked flow, unable to
effectively discover
important information
about patient.
Nurse appears stressed out,
lacks organization, or is
disorganized.
Does not offer any
and Interventions
Recommendations
6.
recommendations to the
patient.
Overuse or reliance on
doctor recommendations for
problems that can be
addressed by nurse.
SBAR was communicated to
SBAR
7.
the health care team
member, but was ineffective
and/or untimely. The
communication lacked
confidence, flow, and was
not concise.
Recommendations were not
offered.
Developing
2 3
Gathering subjective data
was attempted, but lacked
depth and direction.
Patient’s questions or
concerns were not
addressed.
Nurse appears reluctant to
ask subjective questions.
Offers limited
recommendations that do
not address the patient’s
concerns.
Recommendations are not
evidence-based health
interventions and/or lack
depth or clarity.
✔ ✔ ✔
SBAR was communicated to
the health care team, but > 3
components were missing.
Communication lacked only
one of the following:
confidence, flow, timely.
Recommendations were
incomplete, inappropriate, or
out of the nurse’s scope of
practice.
✔ ✔ ✔
Proficient
Utilizing subjective data, the
nurse was able to evaluate
most (but not all) of the
following: mental status,
pain, nutritional status,
spiritual health, psychosocial
wellbeing, and family
function. Nurse appears calm
and confident with clear
communication.
✔ ✔ ✔
Recommends less than 3
evidence-based health
interventions that address
problems identified in the
physical assessment.
Does not ask the patient to
verbalize understanding or
use teach back techniques.
SBAR was communicated
effectively and timely to the
health care team, but was out
of order.
Recommendations were
given, but were incomplete
or lacked appropriate depth.
Achieved > 3 of the SBAR
components.
Distinguished
4
Used subjective data to
assess the patient’s mental
status, pain, nutritional
status, spiritual health,
psychosocial wellbeing, and
family functioning were
appropriately evaluated.
Nurse appears calm and
confident with clear
communication.
Recommends 3-5 evidence-
based health interventions
that address problems
identified in the physical
assessment.
Asks patient to verbalize
understanding or uses teach
back techniques.
SBAR was communicated to
the health care team
effectively and timely. Each
area within SBAR was given
in the correct order was
thorough yet concise.
Appropriate
recommendations were
offered.
 Peer comments* (2 compliments and 2 recommendations)
Kim's therapeutic communication was well and gave good recommendations for the patient to help the patient relieve pain
and discomfort from the headache. She missed some points in the head to Toe assessment. Be more confident in the nursing
skills you perform.

Student comments (2 strengths and 2 opportunities for improvement) Midterm Final

I think that I did well with knowing my head to toe more from last time as well as I think I did well for my focused assessment.
I need to work on my SBAR in organizing it as well as remember the rest of my head to toe assessment.

Faculty comments Midterm Final

Nice use of open ended questions
Continue to work on gathering subjections
Consider pulling up a chair to talk with patient
Continue to work on finding interventions and teaching opportunities
Practice SBAR

*Peer comments not needed in clinical setting

Faculty Signature: Tina Robins

Student Signature: Kimberly Knecht

✔ Satisfactory Unsatisfactory Needs Remediation/Statement of Concern