Sterile Technique and Wound Care: A Checklist for Nursing Students | Summaries Nursing

Physical Assessment—Pass Off

Student: ____________________________ Instructor: __________________________

General Observations: Vital Signs Mental Status Measurements  (done in advance)

Vision: Snellen or Rosenbaum (done in advance and reported to lab instructor @ pass-off) 2 points

Skin: (done throughout exam) inspect lesion/nevi/scars temperature turgor

Head: scalp hair nodules

Face: facial movements/ CN VII  facial sensations/CN V palpate muscles/CN V temporal arteries

Eyes: eyebrows/eyelashes/eye lids conjunctiva

corneal light reflex pupils equal response direct/consensual to light & accommodation EOMs 

Ears: external inspect/palpate otoscope hearing: whisper Weber & Rinne

Nose: patency (& CN I)  internal mucosa & nasal septum tenderness palpate or percuss sinuses

Mouth: lips oral mucosa teeth & gums tongue m/l  tongue movement/CNXII

“ah”/soft palate/uvula /CN X tonsils/palatine arches gag reflex/CN X

Neck: lymph nodes trachea m/l ROM strength against resistance/CNXI 

shrug shoulders/CNXI  carotid arteries

Thorax/posterior: inspection symmetry chest expansion percuss percuss CVA tenderness auscultate

RML: auscultate  Anterior: auscultate (examiner requests deep breaths in & out through mouth before auscultating )

Cardiovascular: pulsations/heaves/lifts PMI auscultate: sitting, diaphragm & bell supine, diaphragm & bell)

Abdomen: inspect auscultate BS/bruits percuss (4 quads, liver)  light palpate (tenderness) 

deep palpation (masses, liver, spleen) (examiner requests knees flexed before palpation )

Upper Ext: Inspect: arms/hands/fingers  nail plate angle/curvature  Palpate: capillary refill  handgrip  Pulses: radial  brachial

Lower Ext:: Inspect: legs/feet/toes/nails Palpate: capillary refill edema Pedal Pulses: dorsalis pedis posterior tibial

Muscle strength: upper extremities  lower extremities 

Sensory: light touch  location/vibration  sharp/dull  proprioception 

Coordination: rapid alternating movements heel to shin

Reflexes: biceps & triceps  knee jerk & achilles  plantar 

ROM: upper extremities (shoulders, elbow, wrist, hands, fingers)  lower extremities (hips, knees, ankles, feet, toes)  spine 

Ambulation/Gait/Balance: gait Romberg

Spine: inspection palpation (points from Skin-Spine = 1 point/square, total 85 points) sub-total _____/87

Professional dress yes no



hand hygiene: yes no



Equipment yes no



& Pass-off form: yes no



(1/2 point for each)

Explains procedures to client: always usually (2 points) sometimes



(1 point)

Organized & follows general order: always usually (skips back x1-2)  (2 points) sometimes (skips back 3)



(1 point) >3



(0 points)

Refers to 3X5 card: end of exam only  rarely (once during exam & once @ end)  (2 points) occasionally (2-3 during exam)



(minus 1)

often (>3 during exam)



(minus 2 points)

Performs skills/techniques correctly: always usually (1 incorrect)  (3 points) sometimes (2 techniques incorrect)



(1 point)

≥

3 techniques incorrect



(0 points)

Complete in ≤ 40 minutes (2 points) Required excessive time >40 minutes (0 points) 

start time___________ completion time______________

Comments/suggestions: Final Score _____/100

=completed

= not completed

= skipped back

to complete

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Physical Assessment—Pass Off

Student: ____________________________ Instructor: __________________________

General Observations: Vital Signs Mental Status Measurements  (done in advance)

Vision : Snellen or Rosenbaum (done in advance and reported to lab instructor @ pass-off) 2 points

Skin: (done throughout exam) inspect lesion/nevi/scars temperature turgor

Head : scalp hair nodules

Face : facial movements/ CN VII  facial sensations/CN V palpate muscles/CN V temporal arteries

Eyes : eyebrows/eyelashes/eye lids conjunctiva

corneal light reflex pupils equal response direct/consensual to light & accommodation EOMs 

Ears : external inspect/palpate otoscope hearing : whisper Weber & Rinne

Nose : patency (& CN I)  internal mucosa & nasal septum tenderness palpate or percuss sinuses

Mouth : lips oral mucosa teeth & gums tongue m/l  tongue movement/CNXII

“ah”/soft palate/uvula /CN X tonsils/palatine arches gag reflex/CN X

Neck : lymph nodes trachea m/l ROM strength against resistance/CNXI 

shrug shoulders/CNXI  carotid arteries

Thorax/posterior : inspection symmetry chest expansion percuss percuss CVA tenderness auscultate

RML: auscultate  Anterior : auscultate (examiner requests deep breaths in & out through mouth before auscultating )

Cardiovascular : pulsations/heaves/lifts PMI auscultate: sitting, diaphragm & bell supine, diaphragm & bell)

Abdomen : inspect auscultate BS/bruits percuss (4 quads, liver)  light palpate (tenderness) 

deep palpation (masses, liver, spleen) (examiner requests knees flexed before palpation )

Upper Ext: Inspect: arms/hands/fingers  nail plate angle/curvature  Palpate: capillary refill  handgrip  Pulses : radial  brachial

Lower Ext: : Inspect: legs/feet/toes/nails Palpate: capillary refill edema Pedal Pulses : dorsalis pedis posterior tibial

Muscle strength : upper extremities  lower extremities 

Sensory: light touch  location/vibration  sharp/dull  proprioception 

Coordination : rapid alternating movements heel to shin

Reflexes : biceps & triceps  knee jerk & achilles  plantar 

ROM : upper extremities (shoulders, elbow, wrist, hands, fingers)  lower extremities (hips, knees, ankles, feet, toes)  spine 

Ambulation/Gait/Balance : gait Romberg

Spine : inspection palpation (points from Skin-Spine = 1 point/square, total 85 points) sub-t otal _____/

Professional dress yes  no  hand hygiene : yes no  Equipment yes no  & Pass-off form : yes no  (1/2 point for each)

Explains procedures to client : always usually (2 points) sometimes  (1 point)

Organized & follows general order : always usually (skips back x1-2)  (2 points) sometimes (skips back 3)  (1 point) >3  (0 points)

Refers to 3X5 card : end of exam only  rarely (once during exam & once @ end)  (2 points) occasionally (2-3 during exam)  (minus 1)

often (>3 during exam)  (minus 2 points)

Performs skills/techniques correctly : always usually (1 incorrect)  (3 points) sometimes (2 techniques incorrect)  (1 point)

≥ 3 techniques incorrect  (0 points)

Complete in ≤ 40 minutes (2 points) Required excessive time >40 minutes (0 points) 

start time___________ completion time______________

Comments/suggestions: Final Score _____/

= completed

= not completed

= skipped back

to complete

(colors may vary by manufacturer – read the attachment )

N 295 Skills Lab: 9 Steps of Medication Administration

Compare Chart to MAR

Usually at the start of the shift the RN will sit down with

the chart to look at the actual orders and the patient’s

allergies and be sure that these match the MAR. The

order is the highest level of data and the most accurate,

sometimes errors in transcription occur when someone

types up the MAR. If there is a discrepancy that cannot

be resolved by looking back to the original order then

the provider must be called to clarify. In our lab we

won’t do this step because of time constraints.

Calculation & Information

Nurses should have a working knowledge of all the drugs

they administer. Often a quick check in the drug guide is

needed. It is important to know if the ordered dose falls

within the usual dose parameters, the side effects of the

drug, and any special things that need to be assessed

before administering the drug. The drug guide has a

special section on administration that lets nurses know if

a pill can be crushed, if one medication can be mixed

with another, if the medication can be taken with meals

etc. Nurses need to be especially careful when doing

calculations. It is never a bad idea to have another nurse

double check the calculation.

Gather Supplies

Thinking ahead about what supplies you will need saves

a lot of time and steps. Before gathering your supplies

perform hand hygiene. Be sure you have everything you

need and then as always, perform hand hygiene on the

way into the room. Medications are often prepared in

the patient room and that is how we will practice. Some

facilities are set up so that nurses prepare medications at

Student: __ Instructor:

start time_ completion time____