OBJECTIVE STRUCTURED CLINICAL ASSESSMENT

(OSCA) RUBRICEMERGENCY NURSING

ASSESSMENT FORMAT: Collar Neck Installation ProcedureCOURSE : Emergency Nursing

Student name: NIM: Date:No Activity Score Comme

nt0 1 2 3 4PsychomotorPre-interaction Phase

1 Identify indications: there are crepitation and deformities in the cervical bone.

2 Prepare patient and tools (Collar Neck), greet, and explain the purpose and procedure of actionOrientation Phase

3 Introduce self,explain the purpose of the intervention and explain the procedure of action

4 Prepare an informed consent sheet/ask about the patient's willingnessWorking Phase

5 Prepare the tools: Neck collar according to size, sand pillow, and Handscoon. The key is the patient at a distance based on the imagination of pulling a line across the shoulder, where the collar will be attached, and the bottom of the patient's chin. The key to the collars is the distance between the backside of the back and the bottom of the hard plastic that is circular. When the client is placed in a neutral position, use your fingers to measure the distance from the shoulder to the chin.

6 Use handscoon (optional)7 Position the patient comfortably: Supine, anatomic neck8 Recite Basmallah9 Hold the head by holding the mandible toward the

temporal with both hands between the sides (like a jaw-thrust maneuver)

10 Insert the neck collar slowly into the back of the neck with a little past the neck/with a friend’s assistance

10 Place the bent neck collar right on the chin

11 Stick the two sides of the neck collar to each other12 Check: The installation should not be too strong and too loose

13 Put a sand pillow by the patient's head14 Observe patient comfort15 Remove the handscoon16 Recite Alhamdulillah17 Wash hands18 Document itPsychomotor total score = (40:4) x 10 =100Examiner: Signature:

RUBRIC : Overall Assessment of Collar Neck Installation ProceduresCOURSE: Emergency Nursing

NO

Rated aspect

Score

0 1-25 26-50 51-75 76-100If the

student does not do the

points at all

If the student does one

point

If the student

does two points

If the student

does three points

If the student does

all points

1 Cognitive- Identify the problems according to

case scenarios- Think critically

- Identify appropriate interventions

- Analyze the procedures

2 Psychomotor- Perform procedures according to the

principle (e.g. sterile/non-sterile, patient's position, etc.)

- Perform the procedure correctly

- Perform the procedure completely

- Maintain patient and nurse safety

3 Empathy- Explore and clarify patient problems

- Demonstrate respect for patients verbally and non-verbally

- Respond and try to feel the patient's feelings

- Show interest and readiness to help patients

4 Communication- Use the language that is easy to understand

- Build trust with patients

- Use voice volume and intonation in accordance with the patient needs

- Conduct open communication

5 Appearance- Have a neat and clean appearance

- Maintain patient privacy and the environment remains conducive- Show politeness with a smile, and greeting

- Show Islamic attitude in the whole procedure (reciting basmallah, hamdallah, and greetings)

ASSESSMENT FORMAT: Endotracheal Tube Installation ProcedureCOURSE : Emergency Nursing

Student name: NIM: Date:No Activity Scor

eComment

0 1 2 3 4PsychomotorPre-interaction Phase

1 Identify indications: Check progress notes2 Prepare tools:

Endotracheal Tube (ETT), Laryngoscope set (Handle & Blades), Stilet, 10 ccs Disposable syringe, Jelly, Medicines for paralysis and sedation (spray), Plaster, Stethoscope, Bag Valve Mask with reservoirs connected with 100% oxygen, Suction, Scissors, Oropharyngeal, SarongHands (clean and sterile), Tub of instruments containing sterile duk, forceps, trash bin/kidney dishOrientation Phase

3 Greet and introduce yourself

4 Explain the purpose of the intervention5 Explain the procedure for the actions to be taken

Working Phase6 Wash hands7 Wear personal protective equipment (clean mask and

handscoon)8 Place the sterile duk on an empty tray (take it from the

instrument box using a forceps) and give space to the tray to place the laryngoscope

9 Take sterile gauze using forceps (to prepare jelly) and place it on a sterile duk and put jelly on it.

10 Open the ETT plastic wrap (only base).Develop locking balloons on ETT. Check for leaks in balloons. Deactivate the locking balloon again.

11 Insert the stylet on the ETT. Make sure the tip of the stylet does not exceed the tip of the ETT

12 Open the entire ETT and place at the sterile duk that has been provided while still maintaining the sterile principle

13 Connect the laryngoscope handle to the laryngoscope blades on the holder and check the lights. Place the tray on the space provided

14 Position the head in a neutral (anatomical) position15 Check the suction function and do suction if there is any

indication (a secret or blood that is clogging the patient's airway)

16 Give benzocaine spray/anesthesia spray (reduce gag reflex)

17 Remove the handscoon and replace it with a sterile handscoon18 Open the patient's mouth with a cross finger (using the thumb

and index finger) and the left-hand hold the laryngoscope19 Take a deep breath and hold (as a parameter, if we cannot

hold the breath, it means that the patient also experiences hypoxia. The action is immediately terminated and directly provide adequate oxygenation)

20 Insert the laryngoscope in the right side of the patient's mouth, and move the tongue to the left

21 Lift the laryngoscope upward and forwards with a slope of 45° parallel to the grip axis, do not to use teeth as a fulcrum

22 Visually identify the epiglottis and then the vocal cords (ceilix maneuver)

23 Carefully insert the endotracheal tube into the tracheal without pressing the teeth or tissue in the mouth until it passes through the vocal cords ± 1-2 cm or in adults with ET pipe depths ± 19-23 cm.

24 Lift the laryngoscope25 Hold the endotracheal tube with one hand and take the stylet

with the other hand26 Pump the balloon with sufficient air so it does not come off,

do not over-pump the balloon (10-15 ml)27 Connect with BVM (oxygen)28 Check the placement of the endotracheal tube by ventilating

with BMV that has been attached to oxygen. And visually

note the expansion of the chest by ventilation and auscultation of the chest and abdomen with a stethoscope to ascertain the location of the pipe/see capnographic waves/PETCO2

29 Secure the pipe with plaster30 Install the oropharynx to prevent the patient from biting on

the ET pipe31 Continue to ventilate with 100% oxygen (flow 10-12

liters/minute) with BVM or connect with a ventilator32 Remove the handscoon and wash your hands33 Tidy up the tools34 Document itPsychomotor total score = (40:4) x 10 =100Examiner: Signature:

RUBRIC : Assessment of Endotracheal Hose InstallationCOURSE: Emergency Nursing

NO

Rated aspect

Score

0 1-25 26-50 51-75 76-100If the

student does not do the

points at all

If the student does one

point

If the student

does two points

If the student

does three points

If the student does

all points

1 Cognitive- Identify problems according to case

scenarios- Think critically

- Identify appropriate interventions

- Analyze the procedures

2 Psychomotor- Perform procedures according to the

principle (e.g. sterile/non-sterile, patient's position, etc.)

- Perform the procedure correctly

- Perform the procedure completely

- Maintain patient and nurse safety

3 Empathy- Explore and clarify patient problems

- Demonstrate respect for patients verbally and non-verbally

- Respond and try to feel the patient's feelings

- Show interest and readiness to help patients

4 Communication- Use language that is easy to understand

- Build trust with patients

- Use voice volume and intonation according to patient needs

- Conduct open communication

5 Appearance

- Have neat and clean appearance- Maintain patient privacy and the environment remains conducive- Show politeness with a smile, and greeting

- Show Islamic attitude in the whole procedure (reciting basmallah, hamdallah, and greetings)

ASSESSMENT FORMAT: Oropharyngeal Installation ProcedureCOURSE : Emergency Nursing

Student name: NIM: Date:No Activity Scor

eComment

0 1 2 3 4PsychomotorPre-interaction Phase

1 Identify indications: correct the airway obstructioncaused by an inverted tongue

2 Use gloves/handscoonOrientation Phase

3 Measure the oropharyngeal tube: the appropriate size can be measured by stretching the pipe from the corner of the patient's mouth towards the tip of the ear lobe (the lobules) of the same side of the face. Another method for measuring the tube is by measuring from the middle of the patient's mouth towards the angle of the lower jawbone

4 Place the patient in the supine position and use the head tilt/chin lift/jaw thrust maneuver method to secure the airway manually.Working Phase

5 Cross your thumb and index finger on the same hand and place them on the upper and lower teeth in the corner of the patient's mouth. Spread your fingers to open the jawpatient (Crossed Finger)

6 Insert the pipe upside down (end of the pipe facing the palate) and run along the bottom of the patient's mouth, passing through the soft tissue hanging from the back (uvula) or until you find a barrier against pallatum Molle

7 Carefully rotate the oropharyngeal airway 180 degrees so that the tip is directed downward to the patient's pharynx.

8 Place the non-traumatic patient in the head tilt position. If there is a possibility of cervical injury, maintain neck stabilization at all times during airway management

9 Check and see the patient's response after the pipe is installed.Make sure the pipe is installed properly and the size is appropriate.

10 Evaluation: Monitor patients closely. If there is a gag reflex immediately remove the oropharynx directly. Remove the breathing apparatus by following the anatomic curve. You do not have to rotate the breathing apparatus when removing it

11 Remove Handscoond12 Bandage to minimize breathing apparatus13 Document:

Respiratory status before the action, vital signs, and other indications of respiratory distress after the action, changes in breath sounds, patient response, whether:

Spontaneous breathing/getting adequate gas exchange A foreign object is not in the airway Condition of patient awareness Skin color

Psychomotor total score = (40:4) x 10 =100Examiner: Signature:

RUBRIC : Overall Assessment of Oropharyngeal Installation ProceduresCOURSE: Emergency Nursing

NO

Rated aspect

Score

0 1-25 26-50 51-75 76-100If the student

does not do the points at all

If the student does one point

If the student

does two points

If the student

does three points

If the student does all points

1 Cognitive- Identify problems according to case scenarios- Think critically

- Identify appropriate interventions

- Analyze the procedures

2 Psychomotor- Perform procedures according to the principle (e.g.: sterile/non-sterile, patient's position, etc.)

- Perform the procedure correctly

- Perform the procedure completely- Maintain patient and nurse safety

3 Empathy- Explore and clarify the patient's problem

- Demonstrate respect for patients verbally and non-verbally- Respond and try to feel the patient's feelings

- Show interest and readiness to help patients

4 Communication- Use language that is easy to understand- Build trust with patients

- Use voice volume and intonation according to patient needs

- Conduct open communication

5 Appearance

- Have neat and clean appearance- Maintain patient privacy and the environment remains conducive- Show politeness with a smile, and greeting- Show Islamic attitude in the whole procedure (reciting basmallah, hamdallah, and greetings)

ASSESSMENT FORMAT: Heimlich Maneuver Management ProceduresCOURSE : Emergency Nursing

Name of Student: NIM: Date:No Activity Scor

eComment

0 1 2 3 4PsychomotorPre-interaction Phase

1 Check the victim's condition/observe for signs of airway obstruction and determine the type of blockage that occurs in the client.Ask if the client is choking, whether he can talk or cough, observe anxiety and difficulty in breathing, respiratory strength, and cyanosis. (Recommend coughing as hard as possible if there are cases of obstruction and the client is conscious). For clients with a total blockage will result in unable to talk, breathe, and cough for the client in a conscious state. Whereas in unconscious patients, it will result in breathing stops.Orientation Phase

2 Explain to clients that you have been trained to help in situations like this. Explain the procedure you will do and how the client can work together.Speak slowly, clearly and trustingly

3 Give client privacy. If there is another person who can collaborate, ask the person to seek help. If there are family members, you can ask them to leave the place for a while.

Working Phase4 Open the airway5 If a foreign object is a solid object and is visible, do a finger

sweep. And if foreign objects are not visible, do the Abdominal Truss /Heimlich Maneuver

6 Adjust the position of the victim standing or sitting leaning slightly forward

7 The helper stands behind the victim8 Put your hand around the client9 Make a fist with one hand and place the side of the thumb

above the navel and under the xyphoideus processus10 Hold your fist tightly with your other hand11 Recite Basmallah12 Quickly snap up and do five hits

13 Do an evaluation

If the obstruction does not disappear after a series of actions, adjust your position and the client's airway. Repeat the sequence of process sequences until the blockage is successfully removed

14 Document Respiratory status/airway patency/respiratory distress Vital sign Client response Secure and note any foreign objects that are clogging

Psychomotor total score = (40:4) x 10 =100Examiner: Signature:

RUBRIC: Overall Assessment of Heimlich Maneuver's Management ProceduresCOURSE: Emergency Nursing

NO

Rated aspect

Score

0 1-25 26-50 51-75 76-100If the student does not do the points

at all

If the student does one

point

If the student

does two

points

If the student

does three points

If the student does all points

1 Cognitive- Identify the problem according to the

case scenario- Think critically

- Identify appropriate interventions

- Analyze procedures

2 Psychomotor- Perform procedures according to the

principle (e.g.: sterile/non-sterile, patient's position, etc.)

- Perform the procedure correctly

- Perform the procedure completely

- Maintain patient and nurse safety

3 Empathy- Explore and clarify the patient's

problem- Demonstrate respect for patients verbally and non-verbally- Respond and try to feel the patient's

feelings- Show interest and readiness to help

patients

4 Communication- Use language that is easy to understand

- Build trust with patients

- Use voice volume and intonation according to patient needs

- Conduct open communication

5 Appearance

- Have neat and clean appearance- Maintain patient privacy and the environment remains conducive- Show politeness with a smile, and greeting

- Show Islamic attitude in the whole procedure (reciting basmallah, hamdallah, and greetings)

ASSESSMENT FORMAT: Procedure for Taking Arterial Blood Specimens (Blood Gas Analysis)COURSE: Emergency Nursing

Name of Student: NIM: Date:No Activity Scor

eComment

0 1 2 3 4PsychomotorPre-interaction Phase

1 Identify indications: Check the patient's oxygen concentration level and oxygen administration (oxygen saturation).

2 Check the patient's body temperature3 Prepare a 0.5 mL heparin filled syringe

Hold the syringe upright and remove the air in it4 Tools preparation:

2/3 mL syringe, (23G / 25G), heparin (0.5ml), Stopper, aseptic solution, ice bag, handscoons, goggles, roller towelsOrientation Phase

5 Greet, smile and introduce yourself

6 Explain the purpose of the intervention

7 Explain the procedure for the actions to be taken8 Allow asking questions and asking about the patient’s readiness

Working Phase9 Wash hands10 Use handscoon (goggles)11 Press radial, brachial or femoral arteries (nondominant)12 If the puncture in the radial artery, do the Allen test13 If the patient is conscious:

Press radial arteries and ulna together Ask the patient to clench until it looks pale Release the pressure on the ulnar artery (while still

compressing the radial artery). Pay attention to skin color within 15 seconds.

14 If the patient is unconscious:

Simultaneously press the radial artery and ulna on the wrist Elevate the patient's hand above the heart and squeeze the hand

until it looks pale Lower the patient's hand while still pressing on the radial artery

(releasing the ulnar artery) and see the skin color in 15 seconds.

15 If the location is punctured radially, position the palm, looking up and slightly hyperextended, place a small towel roll on the patient's wrist

16 Search the radial artery pulses that feel the hardest with the index finger and middle finger

17 Give disinfectant in the puncture area, and make sure it is dry after administration.

18 Insert the 90° needle into the area of the artery that has been selected while pressing on the artery. There's no need to pull the plunger because arterial blood pressure will automatically fill the syringe.

19 After arterial blood has been obtained, pull the needle and apply firm pressure over the puncture with dry gauze (for 3-5 minutes).

20 And close the syringe with a material that is not permeable to the air (stopper).

21 Give a label22 Place the syringe in the ice23 Observe the patient's condition24 Contract next action25 Recite hamdallah, say goodbye and greetings26 Send specimen results immediately27 Follow up after 10-15 minutes28 Palpate the pulse, check to forge the puncture, and assess tingling,

discoloration, dengue sensation in the patient29 Document:

Response during Activity, temperature, oxygen administrationScore total Psychomotor = (40:4) x 10 =100Examiner: Signature:

RUBRIC: Overall Assessment of Arterial Blood Specimen Collection (AGD)COURSE: Emergency Nursing

NO

Rated aspect

Score

0 1-25 26-50 51-75 76-100If the

student does not do the

pointsat all

If the student does one

point

If the student

does two

points

If the student

does three points

If the student does all points

1 Cognitive- Identify the problem

according to the case scenario

- Think critically

- Identify appropriate interventions- Analyze procedures

2 Psychomotor- Perform procedures

according to the principle (e.g. sterile / non-sterile, patient's position, etc.)Perform the procedure correctly

- Perform the procedure completely- Maintain patient and nurse safety

3 Empathy- Explore and clarify the

patient's problem- Demonstrate respect for patients verbally and non-verbally- Respond and try feel the

patient's feelings- Show interest and

readiness to help patients

4 Communication- Use language that is easy to understand- Build trust with patients

- Use voice volume and intonation according to patient needs

- Conduct open communication

5 Appearance

- Have neat and clean appearance

- Maintain patient privacy and the environment remains conducive- Show politeness with a smile, and greeting- Show Islamic attitude in the whole procedure (reciting basmallah, hamdallah, and greetings)

ASSESSMENT FORMAT: Procedure for Pulmonary Resuscitation TreatmentCOURSE : Emergency Nursing

Name of Student: NIM: Date:No Activity Scor

eComment

0 1 2 3 4PsychomotorPre-interaction Phase

1 Identify indications (secure rescuers, secure patients (transportation: use the log roll technique if the patient is found to be in an unsafe environment and ascertain the patient is free of cervical injury (cervical check), secure the environment)

2 Ensure the level of patient consciousness (pat and shake the patient slowly. Call and ask the patient’s condition).

Orientation Phase3 Monitor breathing (No Breathing, Only Gasping)

4 Seek help immediately (EMS) (state name, cellphone number, number of patients, condition, address)

5 Assess for cardiac arrest (carotid pulse for 10 seconds)Working Phase

6 Position the client (position supine based on whichhard)

7 Position yourself properly by squatting beside the victim's right, parallel to the victim's shoulder

8 Give chest compression (if the confirmed carotid pulse is not palpable)Adjust the position of the hand above the sternum.Use your middle and index fingers to determine the location of the lower border of the rib cage

9 Place the heel of the other hand lengthwise under the client's sternum, close to the index finger beside the middle finger

located at the meeting point of the sternum ribs

10 Then place the first hand on the second hand so that the two hands are parallel. The radius is an extension or interrelated.

11 Recite Basmallah12 Perform cardiac compression (30 times, 5cm deep)

Lock your elbows in position, straighten your arms and position your shoulders just above your hands

Give external heart compression with a speed of at least 100 times per minute. Maintain the rhythm of the count by saying "and one, and two, and three, and four, and five, and six, and seven, eight, nine, ten".

13 When the compression pause, release all compression pressure.However, do not move your hands from your chest or change position.

14 Give ventilation twice by opening the patient's mouth using the head-tilt-chin-lift method or jaw-thrust maneuver (mouth to mouth)

15 Do it for five cycles (five compressions five vents)16 Observe and review of respiratory disorders (look, listen and

feel)17 Assess carotid pulse18 If the pulse is not palpated, the helper who originally

gave the compression said "there was no pulse - start compression" and the RJP was continued (2 helpers), continue the RJP (1 helper)

When the situation recovers with CPR (palpable pulse)Give a steady position or recovery (mentioned above). Provide emotional support to the client's family members and others who witness a cardiac arrest. This situation can often be frightening for others because it suddenly and seriously happens.

19 Document

It comprises of the date and time of occurrence of pulmonary arrest, including triggering events, duration of pulmonary arrest, and resuscitation of client responses. Record vital signs and types of follow-up care, indications of stopping the CPR action.

20 Note:

Indications for stopping RJP:

Trained helpers take over The victim's heart rate and breathing have recovered Additional life support measures began It was stated that the client has died Helpers are exhausted and no one else replaces

Score total psychomotor = (40:4) x 10 =100Examiner: Signature:

RUBRIC : Overall Assessment of Lung Cardiac Resuscitation Procedure CURRENCY: Emergency Nursing

NO

Rated aspect

Score

0 1-25 26-50 51-75 76-100If the

student does not do the pointsat all

If the student

does one of

the points

If the student

does two

points

If the student

does three points

If the student does all points

1 Cognitive- Identify the problem

according to the case scenario

- Think critically

- Identify appropriate interventions- Analyze the procedures

2 Psychomotor- Perform procedures

according to the principle (e.g.: sterile / non-sterile, patient's position, etc.)Perform the procedure correctly

- Perform the procedure completely- Maintain patient and nurse safety

3 Empathy- Explore and clarify the

patient's problem- Demonstrate respect for patients verbally and non-verbally

- Respond and try to feel the patient's feelings

- Show interest and readiness to help patients

4 Communication- Use language that is easy to understand- Build trust with patients

- Use voice volume and intonation according to patient needs

- Conduct open communication

5 Appearance

- Have neat and clean appearance

- Maintain patient privacy and the environment remains conducive- Show politeness with a smile, and greeting- Show Islamic attitude in the whole procedure (reciting basmallah, hamdallah, and greetings)