ILOILO DOCTORS’ COLLEGE

COLLEGE OF NURSING
West Avenue, Molo, Iloilo City
5000 Philippines

FORM1.14: MODIFIED SKILL REVIEW FORM: FOCUSED ADULT PHYSICAL ASSESSMENT ORGAN OR SYSTEM:
PERIPHERAL CIRCULATION

Instruction: mark each item by encircling the number corresponding to the student’s performance.

Scoring and Description:

5 (100%) : complete and accurate testing or procedure; correct use of instrument(s)/ equipment, correct/ accurate
statement of findings or complete testing or procedure; correct/ accurate statement of findings.
4 (90%) : complete testing or procedure; correct use of instrument(s)/ equipment; with minimal errors in testing and
statement of findings or complete testing; with minimal errors in testing and statement of findings.
3(80%) : incomplete testing or procedure, with minor steps in testing omitted or absent; minor error/s in use of
instrument(s) / equipment; minor errors in statement of findings noted or incomplete testing or procedure,
with minor steps in testing omitted or absent; minor errors in statement of findings noted.
2 (70%) : incomplete and inaccurate testing or procedure4, with major errors or critical steps in testing omitted or
absent; incorrect use of instrument(s)/ equipment; major errors and incomplete statement of findings of
findings or incomplete and inaccurate testing or procedure, with major errors or critical steps in testing
omitted or absent; major errors and incomplete statement of findings.
1 (60%) : Failure to perform test or procedure; no statement of findings provided.

ASSESSMENT 5 4 3 2 1
(100%) (90%) (80%) (70%) (60%)
1. Washed hands 5 4 3 2 1
2. Identifies client (significant other or partner), and self to 5 4 3 2 1
client (significant other or partner0, and established rapport
3. Provided privacy and explained procedure, and how client 5 4 3 2 1
can cooperate.
4. Obtained consent 5 4 3 2 1
5. Prepared/ assembles required equipment or instruments. 5 4 3 2 1
6. Wore gloves, as indicated or appropriate 5 4 3 2 1
7. Positioned client appropriately. 5 4 3 2 1
8. Checked and compared skin color, venous pattern and 5 4 3 2 1
temperature to upper and lower extremities.
9. Checked for lesions, ulcer, and edema to upper and lower 5 4 3 2 1
extremities.
Identified, palpated, and graded amplitude of peripheral ( arterial) pulsed, as follows:
10. Temporal 5 4 3 2 1
11. Carotid 5 4 3 2 1
12. Radial 5 4 3 2 1
13. Brachial 5 4 3 2 1
14. Ulnar 5 4 3 2 1
15. Femoral 5 4 3 2 1
16. Popliteal 5 4 3 2 1
17. Dorsalis pedis (pedal) 5 4 3 2 1
18. Posterior tibial 5 4 3 2 1
Performed the following Special Test
19. Allen 5 4 3 2 1
20. Burger 5 4 3 2 1
21. trenddelenburg 5 4 3 2 1
22. manual compression test 5 4 3 2 1
23. capillary Refill 5 4 3 2 1
24. homan’s (by checking and measuring methods only) 5 4 3 2 1
25. Edema (and graded, if present) 5 4 3 2 1
26. Provided client after- care, as appropriate. 5 4 3 2 1
27. Ensured client safety and comfort. 5 4 3 2 1
28. Cleaned and disinfected used equipment, as 5 4 3 2 1
appropriate.
29. Removed and disposed gloves and used material(s) 5 4 3 2 1
appropriately.
30. Washed hands 5 4 3 2 1
31. Documented findings. 5 4 3 2 1
TOTAL
Comments:_______________________________________________________________________________________
__________________________________________________________________________

wSignature of clinical instructor:_______________________ Student’s Signature:_______________

Date:_________________________ Date: __________________________