1st Attempt________

2nd Attempt________
3rd Attempt________

Student Name:________________________________Evaluator:_____________ GRADE:____/100

*Must achieve 85%
UNIVERSITY OF ALABAMA AT BIRMINGHAM
SCHOOL OF NURSING

FOCUSED ASSESSMENT CHECK OFF RUBRIC: NUR 389L

NOTE: All students will be evaluated on safety, communication, professionalism, organization

general survey, and SBAR reporting. Each student will then be evaluated on 1 of the 5 following focused
assessments: HEENT, Respiratory, Cardiovascular, Gastrointestinal, Musculoskeletal/Neurological.
15 minutes per attempt will be allotted for each student.
Faculty will stop grading after time limit and all missing items will be deducted.

SKILL Comments

GENERAL EXPECTATIONS: (10 pts)

SAFETY:
o Hand hygiene prior to exam 1 pt
o Hand hygiene after exam 1 pt
o Bed low/locked, hand rails up after exam 1 pt
o Call light within reach after exam 1 pt
o Patient safety considered throughout entire validation 1 pt

COMMUNICATION:
o Introduces self to patient 0.5 pt
o Verifies patient’s identification (2 identifiers) using armband and medical record 1 pt
o Explains exam to patient throughout 1 pt
o Speaks clearly/uses appropriate terms 1 pt
o Concludes exam and thanks patient 0.5 pt

PROFESSIONALISM:
o Demonstrates sensitivity by draping patient appropriately throughout exam 1pt

TOTAL POINTS: ____/10_

GENERAL SURVEY (must state findings): (5 pts)

o Overall physical and sexual development 0.5pt
o Apparent age with stated age 0.5pt
o Overall skin coloring 0.5pt
o Dress, grooming, hygiene 0.5pt
o Behavior 0.5pt
o Presence of distress and/or pain 0.5pt
o LOC 0.5 pt (Alert, lethargy, obtunded, stupor, coma)
o Orientation (X3: person, place, time) 0.5pt
o Posture/body movements 0.5pt
o Speech 0.5pt

TOTAL POINTS: ____/5_

FOCUSED GASTROINTESTINAL/GENITOURINARY: (80 points)

Gastrointestinal
Inspect:
o Overall skin color 2 pt
o Vascularity 2 pt, striae 2 pt, lesions 2 pt, rashes 2 pt
o Location 2 pt, contour 2 pt, and color 2 pt of umbilicus
o Symmetry 2 pt and contour 2 pt of abdomen
o Aortic pulsations 2 pt

Auscultate:
o 4 quadrants 2 pt
o Note bowel sounds: intensity 2 pt, pitch 2 pt, frequency 2 pt (bowel sounds are
decreased which is expected because of the constipation)
o Uses diaphragm 2 pt
o Vascular sounds: aorta 2 pt and iliac 2 pt and uses bell 2 pt
o Uses proper sequence (starts in RLQ) 1 pt
o Auscultates before percussing/palpating 3 pt

Percuss:
o 4 quadrants 2 pt
o Note tone over quadrants 2 pt
o Uses proper sequence (starts in RLQ) 1 pt

Palpate: while im palpating let me know if you feel any discomfort or pain. (yes I feel
some discomfort and pain)
o 4 quadrants 2 pt
o Note absence/presence of tenderness/muscular resistance 2 pt
o Uses proper sequence (starts in RLQ) 1 pt

Note:
o Last BM 2 pt, stool consistency 2 pt and color 2 pt (when was the last time you had a
bowel movement? Ive been constipated periodically for a while but my last bowel
movenmt was yesterday. It brown but it looked like it had red streaks in it and it was
formed.)
o Incontinence 2 pt Do you have any trouble going to the bathroom? Ive been
constipated for a while.
o Collection devices 2 pt, feeding tubes 2 pt

Genitourniary
Inspect:
o Color 2 pt and clarity 2 pt of urine
Palpate:
o The bladder 2 pt
o CVA tenderness bilaterally 2 pt
Note:
o Collection devices 2 pt or dialysis access sites 2 pt
o Incontinence 2 pt
ORGANIZATION:
 o Uses organized sequence overall 2 pt

Situation: Hi this Kelsey, the nurse taking care of TH. The patient who came into the emergency room.

Backgroud: He is a 57 year old male who came into the emergency room because of severe cramping in his
abdomen along with blood streaked stool. He also reported periopdic constipation. He has some abdominal
discomfort and he says the pain is getting worse,

Assessment: His vital signs are as follows: BP, HR,Temp, RR, O2.

Recommediation: I recommend he get a blood occult test as well as a GI consult for a possible GI bleed.