CLASI Skill Practice Checklist 2020_3_.pdf - CLASI Skills...

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CLASI Skills Practice Skill Category Special Instructions Performed Correctly Needs Improvement Omitted Professionalism and Interpersonal Communication Introduces self (First and Last Name) Introduce self as Nurse Practitioner (NP) or Midwife student Ask Name and DOB / Address by surname May use first name if permission from patient Washes hands before and after exam w soap and water May use hand sanitizer. This MUST be actually done. Ensures patient comfort and privacy Proper draping / Explain all actions to patient prior to performing them Uses equipment correctly Comfortable with the use of all equipment General Survey Patient demeanor/affect/mood Articulate ALL of INSPECTION General appearance Dress/hygiene Height, weight, BMI, stature, nourishment You will not need to measure (data will be provided at CLASI) Skin Inspection/Palpation Skin color, integrity, texture MUST Articulate ALL of Inspection Temperature and moisture Edema Turgor Lesions, scars, tattoos Nail configuration, angle Inspects finger/toe nails Hair distribution, texture, color, quality Head & Face Inspection Configuration, size, contour, position MUST Articulate ALL of Inspection Scalp Skin changes, lesions Symmetry and spacing of facial features Palpation Entire head Gloves not required for hair inspection Temporal arteries Bilaterally Frontal and maxillary sinuses Bilaterally Auscultation Temporal arteries With bell Special Trigeminal nerve (CN V) Motor Clench teeth /TMJ palpation (fingers must be placed anterior to external auditory meatus) Trigeminal nerve (CN V) Sensory Light touch over forehead, cheeks, jaw (In at least 2 places bilaterally) Facial nerve (CN VII) Motor/Sensory Frown, smile, wrinkle forehead, puff cheeks. Eyes Inspection Alignment, placement, symmetry Bilaterally MUST Articulate ALL of Inspection Conjunctiva Bilaterally Upper and lower lids Bilaterally Lacrimal ducts Bilaterally Sclera Bilaterally Red reflex Bilaterally with lights off/dimmed Palpation Eyes and external structures Bilaterally Orbit and lactrimal apparatus Bilaterally Special Assessment Optic nerve (CN II) Visual acuity Use Rosenbaum card (must be 14 inches from eyes) test bilateral, corrected, uncorrected Optic nerve (CN II) Visual fields by confrontation Pt/you focus on each other’s eyes. Then wiggle fingers from behind pt’s head to front Optic nerve (CN II) Ocular function by PERRLA Do not forget accommodation. Oculomotor CN III, Trochlear CN IV, Abducens CN VI) 6 cardinal directions of gaze (superior oblique IV- lateral rectus VI- all other -III)
Fundoscopic exam Lights must be dimmed; ophthalmoscope must be no more than 1 ½ inches (4cm) away from patient’s eye; right eye with right eye, left with left Ears Inspection Configuration, positon, alignment Bilaterally MUST Articulate ALL of Inspection Palpation Mobility, tenderness Bilaterally Special Assessment Vestibulocochlear (CN VIII) Whisper test bilaterally – stand 2 feet behind patient with patient’s finger in opposite ear. Weber test with 512Hz tuning fork Fork placed in middle of head; ask "Where do you hear it?" Want to know if one or both ears

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