Nursing Home Grading Rubric Student S Name ______

Nursing Home Grading Rubric Student’s Name ______

Assignment Dates______

Section I Neurological/Cognitive 5. Miscellaneous:

1. Oriented Section V Elimination Gastrointestinal

2. Level of Consciousness (LOC) 1. Mouth

3. Communication 2. Bowels

4. Memory/recall 3. Bowel Program

5. Eyes/vision 4. Miscellaneous

6. Hearing Section VI Urinary

7. Behavior 1. Urine Appearance

8. Miscellaneous 2. Symptoms:

Section II Integumentary/Wound 3. Elimination

1. Appearance 4. Bladder Program

2. Temperature Section VII Reproductive

3. Pain 1. Male Genitalia

Section III Circulatory 2. Female Breasts

1. Pulse 3. Female Genitalia

2. Cardiac Rhythm Section VIII Musculoskeletal

3. Edema 1. Extremities

4. History of: 2. Miscellaneous

Section IV Respiratory Abnormal findings

1. Breath Sounds Special equipment

2. Breathing Effort Diet

3. Cough Bath Activities

4. History of: Diagnoses: September 18, 19, & 20, 2007 Oakwood Nursing Home

This week I was assigned a 97year old white female who had diagnoses of diabetes hypertension, and chronic obstructive pulmonary disease. She previously had a stroke with residual left side weakness. She wore a splint on her left hand and a brace on her left leg.

On Tuesday she was awake and alert lying in bed. I helped her wash her hands, set up her tray, and she fed herself breakfast using adaptive utensils. She ate ¾ of her meal and drank all of her fluids. I gave her a bed bath and she was able to wash her own face, hands and chest. Her skin appeared warm and dry without any broken areas noted. I assisted her with oral care, dressing and helped her brush her hair. She is incontinent of bowel and bladder and wears briefs. She voided and had a small, soft brown bowel movement. I performed peri-care during her bath and applied barrier cream to her perineal area and lotion to her skin. I applied her L hand splint and L leg brace and assisted her to transfer into the wheelchair using the stand and pivot technique. I made her bed, refilled her pitcher and took her to the activity room for Bingo. I left her in the dining room in her wheel chair with the brakes locked. I placed her bed in lowest position with the call signal on the bed and the water pitcher on the over bed table. I reported to my instructor for other assignments.

On Wednesday she was sleeping in bed when I arrived on the unit. I helped her wash her face and hands, set up her tray and she ate ½ of her meal and drank all of her liquids. I assisted her with oral care and transferred her to the WC using the stand & pivot technique. I took her to the shower. She was able to bathe her own face, chest, and hands. I completed her shower including peri-care. I applied barrier cream to her perineum and lotion to her skin. There were no noticeable changes to her skin. I assisted her with dressing and brushed her hair. I returned her to her room to wait for her daughter to visit. She voided in her brief and I performed peri-care and applied a clean brief. She did not have a bowel movement on my shift. I applied her hand splint and leg brace. I changed her linens and made her bed. I left her bed in lowest position with call signal on the bed and a fresh pitcher of water on the over bed table. I reported to my instructor for other assignments.

On Thursday she was awake but confused. She refused to eat any of her meal or drink any fluids. I reported this to her nurse. I gave her a bed bath and she was not able to help with any of her own care today. I performed peri-care, applied barrier cream and applied a clean brief because she had voided during the night. She did not have a bowel movement on my shift. I applied lotion to her skin. She preferred to remain in bed today so I dressed her in a clean gown and made an occupied bed using clean linens. She was turned and positioned on her left side at 10 AM. Her hand splint and leg brace were not applied because she refused them. I left her in bed in lowest position with call signal within reach and fresh water on her over bed table. I reported to my instructor for other assignments.