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Revised Skills For Revision With Marks and Critical Elements
Revised Skills For Revision With Marks and Critical Elements
ELECTROCARDIOGRAM PLACEMENT
Note: Use one (1) gauze swab per stroke and repeat as
necessary
*critical elements
Verbal Response
9 *Orientated (5) 2
Assess the client’s orientation to
Person- what is his name?
Place - where he is?
Time - what month it is?
If he answers correctly, it is recorded as 5.
Confused (4)
If any one of the three items of information is not
provided correctly, it is recorded as 4.
Words (3)
If, the client does not talk sensibly but utters single
word, it is recorded as 3.
Sounds (2)
If the client moans and groans with no recognizable
words, it is recorded as 2.
None (1)
If the client makes no sounds at all, it is recorded as 1.
Not testable (NT)
If the verbal response is not testable, it is recorded as NT
Best Motor Response
10 *Obeys commands (6) 2
Ask the client to perform a two-step action;
grasp and release your fingers with his hand
raise and lower his arms;
put out and put back his tongue.
If the client does this, it is recorded as 6.
Localizing (5)
In a patient who does not obey commands, a central
stimulus is needed for additional information about motor
response.
Central stimulus
Trapezius pinch
Apply pressure by pinching the trapezius muscle with
increasing intensity for up to 10 seconds.
To perform this, place your hand over the client's
shoulder and press your fingers into the muscle above the
shoulder blade.
b. Pressure to the supraorbital notch
If there has been no localizing response to the trapezius
pinch, apply pressure to the supraorbital notch with
increasing intensity for up to 10 seconds.
This is located by feeling along the lower edge of the
upper rim of the orbit until a groove is felt.
If the client moves his hand above the clavicle, or
collarbone it is recorded as 5. After applying central
stimulation and his upper limb does not reach above the
clavicle, then they are either normally or abnormally
flexing.
The assessment of these non-localizing responses is based
on a combination of both peripheral and central stimuli.
After applying peripheral stimulation and the client bends
his elbow and moves the arms rapidly away from the
body, it is recorded as 4.
Abnormal flexion (3)
After applying peripheral stimulation and the client bends
his elbow slowly and the arms comes across the body,
thumb clenched and leg extends, it is recorded as 3.
Extension (2)
If the client extends his elbows rather than flexing them, it
is recorded as 2.
Straightening the elbow constitutes an “extension”
response.
NONE (1)
A patient who makes no response, it is recorded as 1.
Not testable (NT)
If the best motor response is not testable, it is recorded as
NT.
11 *Ensure client’s safety (put side rails up) 2
12 Perform hand hygiene 1
13 *Document the results and refer if necessary 2
*critical elements:
Marks Marks
S# Steps Allocate Comments
d Obtained
*Sensory Perception
6 Hallucinations 2
Illusions
*Assess orientation to:
Time
7 2
Place
Person
*Assess the insight (Awareness of illness)
What brings you here today? What seems to be the
problem?
8 2
What do you think is causing your problems?
How do you understand your problems?
How would you describe your role in this situation?”
*Judgement
How do you plan to get help for this problem?
What will you do when ____________occurs?
How will you manage if __________happens?
9 2
If you found a stamped, addressed envelope on the
street, what would you do with it?
If you were in a movie theater and smelled smoke, what
would you do?
10 *Report abnormal findings 2
Total 20
*critical elements:
13 Turn off the tap of the faucet with the elbow or use a new 2
paper towel to grasp a hand-operated control.
*critical elements:
11 *Hold draw sheet firmly and on the count of three, lift the 2
client towards the side of the bed.
12 *Put client’s hand (inferior) alongside the body. 2
13 *Cross client’s legs. 2
14 Stand opposite each other. 1
15 Hold client’s shoulder and hips. 1
16 Push or pull client to a semi-prone position. 1
17 Place client’s face to the desired side (left or right). 1
18 Straighten client’s (inferior) hand. 1
19 *Flex client’s (superior) elbow and place hand in front of 2
his/her face
20 *Flex client’s (superior) knee 2
21 Place the small pillow under client’s chest. 1
22 *Ensure client’s comfort and safety. 2
*critical elements:
*critical elements
1 Assemble requirement. 1
To remove facemask