NUR 2180: Health Assessment Instructor-Observed Skill Demonstration: Cardiorespiratory System Student Name: ______________________________________ Date: _________________ Points Possible Points Earned Comments Pre-Procedure Steps Knocks 1 Washes hands 1 Identifies the client with 2 identifiers 1 Provides privacy 1 Explains procedure 1 Identifies any issues that may impact client safety or personal safety 1 General Survey Assess level of consciousness 2 Assess skin color 2 Thorax Inspect shape of thorax with comparison of anteroposterior to transverse diameters 5 Assess respiratory rate, rhythm, depth, presence of accessory muscle use or cough 5 Palpate thoracic expansion 5 Palpate for tactile fremitus 5 Lungs Auscultate breath sounds 8 places on anterior thorax (stethoscope on skin) 10 Auscultate breath sounds 8 places on posterior thorax (stethoscope on skin) 10 Auscultate breath sounds 2 places each in axillary area bilaterally (stethoscope on skin) 10 Carotid Artery Palpate carotid pulses (One at a time) 5 Auscultate each carotid artery for bruits (have client hold exhale, and hold breath) 5 Heart Palpate anterior thorax for heave or thrill 5 Auscultate heart sounds in aortic, pulmonic, Erb’s point, tricuspid, and mitral areas (stethoscope on skin) 20 Post-Procedure Steps Inquires if the client is comfortable 1 Student is professional and courteous with their communication 1 Ensures the client has their call light 1 Ensures client’s personal items are within reach (glasses, phone, etc.) 1 Washes hands 1 Total Points Earned of 100 possible Student Name: ______________________________________ Date: _________________ The above named student has: Passed this skill evaluation Failed this skill evaluation and must remediate. Plan for remediation: Student signature and date indicating agreement with remediation plan: _____________________________________ Instructor signature and date indicating agreement with remediation plan: ___________________________________ 09/01/2021 Page 2 of 2 Title: Documentation of problem based assessment of the cardiac system. Purpose of Assignment: Learning the required components of documenting a problem based subjective and objective assessment of cardiac system. Identify abnormal findings. Course Competency: Select appropriate physical examination skills for the cardiovascular and peripheral vascular systems. Instructions: Content: Use of three sections: · Subjective · Objective · Actual or potential risk factors for the client based on the assessment findings with description or reason for selection of them. Format: · Standard American English (correct grammar, punctuation, etc.) Resources: Chapter 5: SOAP Notes: The subjective and objective portion only Sullivan, D. D. (2012). Guide to clinical documentation. [E-Book]. Smith, L. S. (2001, September). Documentation do’s and don’ts. Nursing ...

1. NUR 2180: Health Assessment
Instructor-Observed Skill Demonstration:
Cardiorespiratory System
Student Name: ______________________________________
Date: _________________
Points Possible
Points Earned
Comments
Pre-Procedure Steps
Knocks
1
Washes hands
1
Identifies the client with 2 identifiers
1
Provides privacy
1
Explains procedure
1
Identifies any issues that may impact client safety or personal
safety

2. 1
General Survey
Assess level of consciousness
2
Assess skin color
2
Thorax
Inspect shape of thorax with comparison of anteroposterior to
transverse diameters
5
Assess respiratory rate, rhythm, depth, presence of accessory
muscle use or cough
5
Palpate thoracic expansion
5
Palpate for tactile fremitus
5

3. Lungs
Auscultate breath sounds 8 places on anterior thorax
(stethoscope on skin)
10
Auscultate breath sounds 8 places on posterior thorax
(stethoscope on skin)
10
Auscultate breath sounds 2 places each in axillary area
bilaterally (stethoscope on skin)
10
Carotid Artery
Palpate carotid pulses (One at a time)
5
Auscultate each carotid artery for bruits (have client hold
exhale, and hold breath)
5
Heart

4. Palpate anterior thorax for heave or thrill
5
Auscultate heart sounds in aortic, pulmonic, Erb’s point,
tricuspid, and mitral areas (stethoscope on skin)
20
Post-Procedure Steps
Inquires if the client is comfortable
1
Student is professional and courteous with their communication
1
Ensures the client has their call light
1
Ensures client’s personal items are within reach (glasses, phone,
etc.)
1
Washes hands
1
Total Points Earned

5. of 100 possible
Student Name: ______________________________________
Date: _________________
The above named student has:
Passed this skill evaluation
Failed this skill evaluation and must remediate. Plan for
remediation:
Student signature and date indicating agreement with
remediation plan:
_____________________________________
Instructor signature and date indicating agreement with
remediation plan: ___________________________________
09/01/2021 Page 2 of 2
Title:
Documentation of problem based assessment of the cardiac
system.
Purpose of Assignment:
Learning the required components of documenting a problem
based subjective and objective assessment of cardiac system.
Identify abnormal findings.
Course Competency:
Select appropriate physical examination skills for the

6. cardiovascular and peripheral vascular systems.
Instructions:
Content: Use of three sections:
· Subjective
· Objective
· Actual or potential risk factors for the client based on the
assessment findings with description or reason for selection of
them.
Format:
· Standard American English (correct grammar, punctuation,
etc.)
Resources:
Chapter 5: SOAP Notes: The subjective and objective portion
only
Sullivan, D. D. (2012). Guide to clinical documentation. [E-
Book].
Smith, L. S. (2001, September). Documentation do’s and don’ts.
Nursing, 31(9), 30.
Documentation Grading Rubric- 10 possible points
Levels of Achievement
Criteria
Emerging
Competence
Proficiency
Mastery
Subjective
(4 Pts)
Missing components such as biographic data, medications, or
allergies. Symptoms analysis is incomplete. May contain
objective data.

7. Basic biographic data provided. Medications and allergies
included. Symptoms analysis incomplete. Lacking detail. No
objective data.
Basic biographic data provided. Included list of medications and
allergies. Symptoms analysis: PQRSTU completed. Lacking
detail. No objective data. Informatio n is solely what “client”
provided.
Basic biographic data provided. Included list of medications and
allergies. Symptoms analysis: PQRSTU completed. Detailed. No
objective data. Information is solely what “client” provided.
Points: 1
Points: 2
Points: 3
Points: 4
Objective
(4 Pts)
Missing components of assessment for particular system. May
contain subjective data. May have signs of bias or explanation
of findings. May have included words such as “normal”,
“appropriate”,
“okay”, and “good”.
Includes all components of assessment for particular system.
Lacks detail. Uses words such as “normal”, “appropriate”, or
“good”. Contains all objective information. May have signs of
bias or explanation of findings.
Includes all components of assessment for particular system.
Avoided use of words such as “normal”, “appropriate”, or
“good”. No bias or explanation for findings evident Contains
all objective information
Includes all components of assessment for particular system.
Detailed information provided. Avoided use of words such as
“normal”, “appropriate”, or “good”. No bias or explanation for
findings evident. All objective information

8. Points: 1
Points: 2
Points: 3
Points: 4
Actual or Potential Risk Factors
(2 pts)
Lists one to two actual or potential risk factors for the client
based on the assessment findings with no description or reason
for selection of them. Failure to provide any potential or actual
risk factors will result in zero points for this criterion.
Brief description of one or two actual or potential risk factors
for the client based on the assessment findings with description
or reason for selection of them.
Limited description of two actual or potential risk factors for
the client based on the assessment findings with description or
reason for selection of them.
Comprehensive, detailed description of two actual or potential
risk factors for the client based on the assessment findings with
description or reason for selection of them.
Points: 0.5
Points: 1
Points: 1.5
Points: 2