Summary
Summary NURS 612 Final Head to Toe Video Rubric
- Course
- NURS 612
- Institution
- Maryville University Of St. Louis
Head to Toe Assessment for Nurs 612.
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NURS612 FINAL HEAD TO TOE VIDEO RUBRICUse of appropriate equipment is required for
skills videos. Submissions without required
equipment will receive zero points and
students will forfeit their attempt.
Examination must be performed on both
sides of the body unless stated otherwise.
Pre-procedure requirements and exam integration
(9 points)
__/ 1 point: Washes hands/uses sanitizer.
__/ 1 point: Introduces self to patient.
_/ 1 point: Identifies the patient using two identifiers.
__/ 1 point: Provides privacy & appropriate environment.
__/ 1 point: Professional demeanor and appearance.
__/ 4 points: Integrates exam components to minimize patient position
transition and provide for efficient flow of exam.
Head and Neck Exam
Head (4 points)
__/2 points: Inspect general size and contour of the skull, noting
deformities, depressions, lumps, or tenderness.
__/2 points: Inspect the face, noting expression, contour, symmetry,
involuntary movements, edema, and masses.
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, Eyes (30 points)
__/2 points: Inspect eyelids, eyelashes, palpebral fissures, and alignment
of eyebrows.
__/2 points: Inspect lacrimal apparatus, conjunctiva, and sclera, noting
color, swelling, discharge, vascularity, or nodules.
_/2 points: Inspect cornea, lens, and pupils, noting opacities, size, shape,
and symmetry.
_/4 points: Assess visual acuity (CN II). Use a Snellen or Rosenbaum eye
chart; ask the patient to cover one eye and read smallest line possible.
_/2 points: Assess pupillary response to light (direct and consensual).
_/2 points: Assess pupillary response to accommodation.
__/4 points: Assess visual fields by confrontation (CN II).
__/4 points: Assess extraocular movements (CN III, IV, VI), including
convergence, noting nystagmus, and lid lag.
__/8 points: Perform ophthalmoscopic exam, adjusting light, positioning
the patient, and holding the ophthalmoscope correctly to identify red
reflex, optic disc, retina, fovea, and macula.
Ears (18 points)
_/4 points: Inspect the auricles and surrounding tissue for symmetry,
deformities, lumps, and lesions.
_/4 points: Inspect the ear canal, noting discharge, foreign bodies,
redness, swelling, and cerumen.
_/8 points: Perform otoscopic exam, correctly positioning patient, auricle,
and scope.
_/2 points: Test auditory acuity using whisper test (CN VIII). (Stand 1 to 2
feet behind patient and ask them to occlude one ear. You whisper a two-
syllable word in the other ear. Ask patient to repeat word back.)
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