OSCE#1 Student guide - Lecture notes Lecture 1 PDF

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OSCE #1 Documentation (Head to toe Assessment ONLY) OSCE #1 Assessment Testing Client: Louisiana Smith DOB: 12/1/1970 Admit Diagnosis: Pneumonia Signs and symptoms: weakness, SOB, Fever You have 10 minutes to complete your assessment. You have 5 minutes to perform 1 of the 3 skills randomly chosen by faculty. 1. Suction the tracheostomy (#4) 2. Medication Administration (#5) a) Regular Insulin 6 units SC q ac& hs or b) Zofran 4mg IM q 4hrs PRN pain 3. NGT (nasogastric tube) assessment (#6)

You have 10 minutes to calculate intake and output and document your assessment findings only (do not document your skill, ONLY your head to toe assessment). Student

Head to Toe Assessment Testing Criteria Met

* * *

Unmet

Performance Objective

Student enters room Start Time: End Time: Washes hands (perform or verbalize) Introduces self Identifies patient: Asks patient to state name and DOB/Compares to name band Allergies: Asks patient about allergies/Checks for correct allergy band General survey (ABCs) of airway, breathing, circulation, LOC/Pupils (while assessin Vital Signs (verbalize) BP, HR, RR, SPO2, Temp Pain (PQRST or Old Carts; rate on 1-10 scale) Tubes and equipment from source to connection with patient Chest-symmetry, heart sounds, lung sounds anterior, lateral, posterior; Asks about b pain Abdomen inspect contour and distention, dressings, drainage, staple/suture line sounds and assess frequency, palpate for tenderness/firmness, Asks about void vomiting

OSCE #1 Documentation (Head to toe Assessment ONLY) Upper extremities, both sides for color, temp motion (lift and hold), sensation, skin tu presence and strength of radial pulses, cap refill Lower extremities,-both sides color, temp, motion, sensation, skin turgor lesions, ed strength of pedal pulses, cap refill Skin Integrity-overall, back buttocks, heels, other pressure points Focused assessment-if patient complains of symptom with particular body system (

assessment would be done) (May have to prompt student by saying -Patient states Safety issue-tell student something is not safe in room; does student identify safety Teaching-have student identify at least one teaching point for this patient •

Critical Criteria-must have all three completed and miss no more than 2 assessment criteria

SUCCESSFUL

REMEDIATE

Faculty

OSCE #1 Documentation (Head to toe Assessment ONLY)

*Universally accepted abbreviations only for shorthand documentation. *Sign, date and time all documentation...