OBJECTIVE STRUCTURED CLINICAL ASSESSMENT (OSCA) RUBRIC

OF GERONTIC NURSING

OSCA RUBRIC OF GERONTIC NURSING

OBSERVATION OF DECUBITUS RISKS WITH NORTON METHOD

NO Activity Point Yes No

APre-Interaction Phase (10%)      

1

Identifying therapeutic programs (reading cases)

3

Tested by reading the program notes carefully (identity, diagnosis, and program)

Tested by not reading carefully (identity, diagnosis, and program)

2Preparing tools (stationery) 2

Bring the stationery needed Not bringing stationery

3 Washing hands5

Washing hands with the propertools and steps

Not washing hands or washing hands with the impropertools and steps

B Orientation Phase (10%)      

4Introducing self and checking the client's identity 2

Mentioning the name and work area, and confirming the name and age of the client

Mentioning only 3 of the 4 components of nurse’s and client’s identity

5Conveying objectives and procedures 4

Correctly explaining the purpose and action steps

Explaining only the purpose or action steps

6Explaining contract (time, place, action) 2

Confirming the time, place and action

Confirming only 2 of the 3 components namely time, place and action

7 Asking client readiness

2

Correctly confirming the client's readiness to take action

Not confirming client readiness or confirming incorrectly

C Work Phase (65%)      

8

Positioning the client in a comfortable way

5

Along with the patient arranging a comfortable position according to the patient's condition

Not arranging the position or arranging the position not according to client’s conditions

9

Asking the general state of the client (excellent, good, fair, poor) 5

Correctly assessing the state of clients in general (good, fair, poor)

Not assessing or assessing the general state of the client incorrectly

10

Reviewing / observing client’s awareness (composmentis, apathy, sopor / confused, styupor / coma)

10

Providing stimulus / questions and observing client’s responses with a correct level of awareness

Not providing stimulus and not observing client responses or providing stimulus and observing responses incorrectly to client awareness

11

Assessingthe client’s activity (an ambulance, an ambulance with help, only sit down, only sleep)

10

Askingclients to demonstrate and observing the ability of client activities

Not asking clients to demonstrate and not observing the ability of client’s activities or only doing 2 of the 3 activities

12

Assessing Mobility (free mobility, slightly strict mobility, highly strict mobility, unmoved) 10

Asking clients to demonstrate and observing the ability of the client's mobility

Not askingthe client to demonstrate and not observing the ability of the client's mobility or only doing 2 of the 3 components

13

Assessing incontinence (absent, occasionally, uri incontinence, and alvi) 10

Asking uri incontinence and alvi incidentstothe clients

Not asking for incidents of uri incontinence and alvi to the client or only asking 1 of 2 things

14

Assess the results (score <12 high risks, 12-13 moderate risk,> 14 low risks) 10

Calculating the score correctly

Not calculating the scores or calculating incorrectly

15

Assessing the area of decubitus risks (scapula, sacrum, occiput, SIAS, elbows, heels etc.) 5

Observingat least 3 areas of decubitus risks on the client's body

Not observing the areas of decubitus risks on the client's body or observing only 2 areas

D Termination Phase (15%)      16 Conducting evaluation

(Subjective, Objective)

5

Asking the client's feelings towards the nurse's actions and conveying the results of the observation in details

Not asking the client's feelings towards the nurse's actions and not conveying the results of the observation in details or only doing 1 of the 2 activities

17 Delivering RTL

2

Providing relevant follow-up plans related to the results of the assessment

Not providing relevant follow-up plans related to the results of the assessment or providing the irrelevant RTL

18 Conveying the next contract

3

Conveying the contract for the next meeting including the time, place and action

Not conveying the contract for the next meeting including time, place and action or conveying only 2 of the 3 components

19 Washing hands

5Doing handwashing with the propertools and steps

Not doing handwashing or washing hands with the impropertools and steps

  TOTAL 100    

 

HYPERTENSION GYMNASTIC

NO Activity PointYes No

APre-Interaction Phase (10%)   Pre-Interaction Stage (10%) Pre-Interaction Stage (10%)

1 Validating client records 3

Client's records (identity, diagnosis, action, and therapy) are conveyed clearly and completely

Client records (identity, diagnosis, action, and therapy) are conveyed unclearly / incompletely

2Preparing tools and media 3

The appropriate stationery and media are adequatelyprepared.

The appropriate stationery and media are not adequately prepared.

3 Washing hands 4Washing hands with the proper tools and steps

Washing hands (with tools and steps) improperly

B Orientation Phase (10%)   Orientation Phase (10%) Orientation Phase (10%)

4Introducing self and re-checking the client’s identity 2

Introducing the name and work area, and re-checking the identity of the clients correctly

Conveying the purpose and steps of action unclearly

5Conveying the purpose and procedures 4

Conveying the purpose and steps of action clearly

Conveying the purpose and steps of action unclearly

6 Time contract 2The place, type, and duration of the action are clearly stated

The place, type, and duration of the action are stated unclearly

7 Requesting client’sconsent 2

Tested byrequesting client's consent politely

Tested by not requesting client's consent politely

C Work Phase (65%)   Work Phase (65%) Work Phase (65%)

8

Reciting Bismillah, then making an apperception

5

Making an apperception about the definition, goals, benefits, and steps of hypertension gymnastic

Not making an apperception or makingan apperception only 2 of 4 things regarding definition, goals, benefits, and steps in hypertension gymnastics

9

Conveying the urgency and benefits of hypertension gymnastics 10

Conveying the goals and benefits of hypertension gymnastics

Not conveying or only conveying one of the goals and benefits of hypertension gymnastics

10Demonstrating the warming-up stage 10

Demonstrating the warming-up stage correctly

Not demonstratingthe warming-up stage correctly

11

Demonstrating the core stages of hypertension gymnastic 10

Demonstrating the core stage of hypertension gymnastic correctly

Not demonstrating the core stage of hypertension gymnastic correctly

12

Demonstrating the cooling-down stage of hypertension gymnastic 10

Demonstrating the cooling-down stage of hypertension gymnastic correctly

Not demonstrating the cooling-down stageof hypertension gymnastic correctly

13

Guiding the client in demonstrating hypertension gymnastic 15

Optimally guiding the client in demonstrating hypertension gymnastic according to the client's ability

Not guiding the client optimally in demonstrating hypertension gymnastics

14Providing reinforcement

5 Providing realistic reinforcement

Not providing reinforcement or providing unrealistic reinforcement

D Termination Phase (15%)   Termination Phase (15%) Termination Phase (15%)16 Evaluating activities and

reciting Hamdallah

5

Asking the client's feelings towards the nurse's actions and presenting the results of the observation in details

Not asking the client's feelings towards the nurse's actions and not conveying the results of the observation in details or only doing 1 of the 2 mentioned-activities

17 Delivering a follow-up plan

2

Delivering relevant follow-up plans related to the results of the observation and the assessment

Not delivering relevant follow-up plans related to the results of the observation and the assessment or delivering the irrelevant RTL

18 Delivering the next contract

3

Delivering the contract for the next meeting including the time, place and action

Not delivering the contract for the next meeting including time, place and action or delivering only 2 of the 3 components

19 Washing hands

5Doing a handwashing with the proper tools and steps

Not doing a handwashing or washing hands with the improper tools and steps

  TOTAL 100    

 

BRAIN GYMNASTIC

NO Activity Point Yes No

APre-Interaction Phase (10%)      

1 Verification of the 3 Tested by reading the Tested by not reading carefully

therapeutic program (reading cases)

program notes carefully (identity, diagnosis, and program)

(identity, diagnosis, and program)

2

Preparing tools / media (flip sheet / poster / visual aid) 3

The appropriate stationery and media are prepared entirely.

The appropriate stationery and media are not prepared entirely.

3 Washing hands 4Doing handwashing with the proper tools and steps

Not doing handwashing with the proper tools and steps

B Orientation Phase (10%)      

4Introducing self and checking the client's identity

2

Mentioning the name and work area, and confirming the name and age of the client

Mentioning only 3 of 4 components of nurse’s and client’s identity

5Conveying the purposes and procedures 4

Correctly explaining the purpose and action steps

Explaining only the purpose or action steps

6

Delivering contract (time, place, topic)

2The place, type, and duration of the action are clearly stated

The place, type, and duration of the action are unclearly stated

7Asking the client’s readiness

2

Confirming correctly the client's readiness to take action

Not confirming the client’s readiness or confirming incorrectly

C Work Phase (65%)      

8 RecitingBasmalah 3

Reciting Basmalah before taking action to the client

Not recitingBasmalah before taking action to the client

9

Conveying apperception about brain gymnastic

6

Conveying apperception about the definition, purpose, benefits, and steps of brain exercise

Not conveying apperception or conveying apperception only 2 of 4 things regarding the definition, purpose, benefits, and steps of brain exercise

10 Conveying the purpose of brain exercise 6

Conveying the purpose of brain gymnastic to the client

Not conveying the purpose of brain gymnastic to the client

11 Conveying the benefits of brain gymnastic 6

Conveying the benefits of brain gymnastic to the client

Not conveying the benefits of brain gymnastic to the client

12Demonstrating brain gymnastic step by step 15

Demonstrating brain gymnastic step by step to the client

Not demonstrating brain gymnastic step by step to the client

13

Guiding the client to redemonstrate brain gymnastic step by step 15

Guiding the client to redemonstrate brain gymnastic clearlybased on the client's ability

Not guiding the client optimally in demonstrating brain gymnastic

14 Providing reinforcement 6

Providing realistic reinforcement

Not providing reinforcement or providing unrealistic reinforcement

15 Reciting Hamdalah 3RecitingHamdalahupontaking action to the client

Not reciting Hamdalahupon taking action to the client

DTermination Phase (15%)      

16

Conducting evaluation (Subjective, Objective) 8

Asking the client's feelings towards the nurse's actions and conveying the results of the observation in detail

Not asking the client's feelings towards the nurse's actions and not conveying the results of the observation in detail or only conveying 1 of the 2 activities

17

Delivering RTL 3

Delivering relevant follow-up plans related to the results of the assessment

Not delivering relevant follow-up plans related to the results of the assessment or conveying the irrelevant RTL

18

Conveying the next contract 3

Conveying the contract for the next meeting including the time, place and action

Not conveying the contract for the next meeting including time, place and action or conveying only 2 of the 3 components

19

Washing hands 3Doing handwashing with the propertools and steps

Not doing handwashing or washing hands with the impropertools and steps

20 Documentation 3Conducting documentation upon completingthe action

Not conducting documentation upon completingthe action

  TOTAL 100     

FOOT GYMNASTIC IN DM

NO Activity Point Yes No

APre-Interaction Phase (10%)      

1

Verification of the therapeutic program (reading cases) 3

Tested by reading the program notes carefully (identity, diagnosis, and program)

Tested by not reading carefully (identity, diagnosis, and program)

2

Preparing tools / media (flip sheet / poster / display) 3

The stationery and media are entirely prepared.

The stationery and media are not entirely prepared.

3 Washing hands 4Doing handwashing with proper tools and steps

Doing handwashing with improper tools and steps

B Orientation Phase (10%)      

4Introducing self and checking the client's identity 4

Mentioning the name and work area, and confirming the name and age of the client

Mentioning only 3 of the 4 components of nurse’s and client’s identity

5Conveying purposes and procedures 4

Correctly explaining the purposes and action steps

Explaining only the purpose or the action step

6Conveying the contract (time, place, topic) 4

The place, type, and duration of the action are clearly stated.

The place, type, and duration of the action are unclearly stated.

7 Asking the client’s readiness 3

Confirming correctly the client's readiness to take action

Not confirming the readiness or confirming incorrectly

C Work Phase (65%)      

8

Conducting apperception about foot gymnastic in DM 5

Conducting apperception about the definition, purpose, benefits, and steps of foot gymnastic in DM

Not conducting apperception or conducting apperception on only 2 of 4 things regarding the definition, goals, benefits, and steps of foot gymnastic in DM

9Conveying the purpose of foot gymnastic in DM 5

Conveying the purpose of foot gymnastic in DM to the client

Not conveying the purpose offoot gymnastic in DM to the client

10 Conveying the benefits of foot gymnastic in DM 5

Conveying the benefits of foot gymnastic in DM to clients

Not conveying the benefits of foot gymnastic in DM to clients

11Demonstratingfoot gymnastic in DM step by step 20

Demonstrating foot gymnastics in DM step by step to clients

Not demonstrating foot gymnastic in DM step by step to clients

12

Guiding the client to redemonstrate foot gymnastic in DMbased on the client's abilities 20

Guiding the client to redemonstrate foot gymnasticin DM based on the client's ability clearly

Not guiding the client optimally in demonstrating foot gymnastic in DM

13 Providing reinforcement 5

Providing realistic reinforcement

Not providing reinforcement or providing unrealistic reinforcement

D Termination Phase (15%)      

14Conducting evaluation (Subjective, Objective) 5

Asking the client's feelings towards the nurse's actions and conveying the results of the observation in detail

Not asking the client's feelings towards the nurse's actions and not conveying the results of the observation in detail or only doing 1 of the 2 activities

15 Delivering RTL 2

Providing relevant follow-up plans related to the results of the assessment

Not providing relevant follow-up plans related to the results of the assessment or providing the irrelevant RTL

16Conveying the next contract 3

Conveying the contract for the next meeting including the time, place and action

Not conveying the contract for the next meeting including time, place and action or conveying only 2 of the 3 components

17 Washing hands 5Doing handwashing with the proper tools and steps

Not doing handwashing or washing hands with the improper tools and steps

  TOTAL 100 

  

DECUBITUS WOUND CARE

NO Activity Point Yes No

APre-Interaction Phase (10%)      

1

Verification of the therapeutic program (reading cases) 4

Tested by reading the program notes carefully (identity, diagnosis, and program)

Tested by not reading carefully (identity, diagnosis, and program)

2 Preparing tools/media 3The stationery and media are entirely prepared.

The stationery and media are not entirely prepared.

3Washing hands 4

Doing handwashing with proper tools and steps

Washing hands with improper tools and steps

B Orientation Phase (15%)      

4Introducing self and checking the client's identity 4

Mentioning the name and work area, and confirming the name and age of the client

Mentioning only 3 of the 4 components of nurse’s and client’s identity

5Conveying purposes and procedures 4

Correctly explaining the purpose and action steps

Explaining only the purpose or the action steps

6Conveying the contract (time, place, topic) 4

The place, type, and duration of the action are clearly stated.

The place, type, and duration of the action are unclearly stated.

7 Asking the client’s readiness 4

Confirming correctly the client's readiness to take action

Not confirming readiness or confirming incorrectly

C Work Phase (60%)      

8 Maintaining privacy 4Closing the door and curtains before taking the action

Not closing the door and curtains before taking the action

9

Adjusting the position of the client so that the wound can be seen clearly 4

Helping to position the client so that the wound can be seen clearly

Not helping to position the client to make the wound visible

10Putting up the layer and preparing equipment

4

Putting up the layer on the client and preparing equipment for action

Not putting up the layer on the client and only preparing some tools for action

11Wearing clean gloves

4

Wearing clean gloves properlyNot wearing clean gloves properly

12 Moistening the plaster with alcohol / wash soap and opening the outer layer and clean around

4 Moistening the plaster with alcohol/wash soap and opening the outer layer as well as cleaning around the wound

Notmoistening the plaster with alcohol/wash soap and not opening the outer layer and not cleaning around the wound

the wound and former plaster

and the former plaster and former plaster

13 Opening the inner layer 4 Opening the inner layer Not opening the inner layer

14

Observing the decubitus wound and surrounding skin to determine the degree of injury (color, humidity, diameter, depth) 4

Observing the decubitus wound and surrounding skin to determine the degree of injury (color, humidity, diameter, depth)

Not observing the decubitus wound and surrounding skin to determine the degree of injury (color, humidity, diameter, depth)

15

Gently cleansing the skin around the wound using warm water and soap 4

Gently cleansing the skin around the wound using warm water and soap

Not gently cleansing the skin around the wound using warm water and soap

16 Drying with a towel 4 Drying with a towel Not drying with a towel17 Replacing clean gloves

with sterile gloves 4Replacing clean gloves with sterile gloves

Not replacing clean gloves with sterile gloves

18Cleansing the wound thoroughly with normal saline solution or cleaning agent: using irrigation syringe for the inner wound

4

Cleansing the wound thoroughly with normal saline solution or cleaning agent: using irrigation syringe for the inner wound

Not cleansing the woundthoroughly and not using normal saline solution or cleansing agent

19 Using topical agents if it is prescribed (one of the following agents) 12

Using topical agents to be applied to decubitus wound

Not using topical agents to be applied to decubitus wound

19Enzyme:   Enzyme: Enzyme:

 a. Apply the ointment to the dominant palm  

Apply the ointment to the dominant palm

Not applyingthe ointment to the dominant palm

 

b. Apply a small amount of ointment evenly over the wound, not on the skin around the wound

 

Apply a small amount of ointment evenly over the wound, not on the skin around the wound

Not applying a small amount of ointment evenly over the wound

 

c. Moisten the gauze with physiological fluid, then apply it to the wound, and cover with dry gauze, patch it well  

Moisten the gauze with physiological fluid, then apply it to the wound, and cover with dry gauze, plaster it well

Not moistening the gauze with physiological fluid, not applying it to the wound, covering with dry gauze, and not plastering properly

  Antiseptic (deep wound)   Antiseptic (deep wound) Antiseptic (deep wound)

 a. Apply the ointment to the dominant palm  

Apply the ointment to the dominant palm

Not applying the ointment to the dominant palm

 

b. Apply the ointment evenly to the wound  

Apply the ointment evenly to the wound

Not applying the ointment evenly to the wound

 

c. Place the gauze and tape firmly

 

Place the gauze and tape firmly

Notplacing the gauze and not taping firmly

  Hydrogel agent   Hydrogel agent Hydrogel agent

 a. Apply the ointment to the dominant palm  

Apply the ointment to the dominant palm

Not applyingthe ointment to the dominant palm

 b. Apply hydrogel to the wound surface  

Apply hydrogel to the wound surface

Not applying hydrogel to the wound surface

 

c. Place the soft dry gauze to cover the wound and plaster it firmly  

Place the soft dry gauze to cover the wound and plaster it firmly

Not placing the soft dry gauze tocover the wound and plaster it firmly

  Calcium Alginate   Calcium Alginate Calcium Alginate

 

a. Wrap the wound with alginate using an applicator or gloves  

Wrap the wound with alginate using an applicator or gloves

Not wrapping the wound with alginate using an applicator or gloves

 b. Use soft dry gauze or hydrocolloid on alginate  

Use soft dry gauze or hydrocolloid on alginate

Not using soft dry gauze or hydrocolloid on alginate

 c. Place the gauze and tape firmly  

Place the gauze and tape firmly

Not placing the gauze and tape firmly

20

Changing the position of the client comfortably and not in the part of the wound  

Changing the position of the client comfortably and not in the part of the wound

Changing the position of the client comfortably and not in the part of the wound

21Tidying up the equipment and taking off the gloves  

Tidying up the equipment and taking off the gloves

Not tidying up the equipment and not taking off the gloves

D Termination Phase (15%)      

22Conducting evaluation (Subjective, Objective) 4

Asking the client's feelings towards the nurse's actions and conveying the results of the observation in detail

Not asking the client's feelings towards the nurse's actions and not conveying the results of the observation in detail or only doing 1 of the 2 activities

23

Providing RTL

3

Providing relevant follow-up plans related to the results of the assessment

Not providing relevant follow-up plans related to the results of the assessment or providing the irrelevant RTL

24

Conveying the next contract

3

Conveying the contract for the next meeting including the time, place and action

Not conveying the contract for the next meeting including time, place and action or conveying only 2 of the 3 components

25 Washing hands 3 Doing handwashing with the proper tools and steps

Not doing handwashing or washing hands with the impropertools and steps

26

Documentation

4Conducting documentation uponcompletingthe action

Not conducting documentation upon completing the action

  TOTAL 100     

ASSESSMENT OF BPH RISK

NO Activity Point Yes No

A Pre-Interaction Phase (10%)      

1

Verification of the therapeutic program (reading cases)

4

Tested by reading the program notes carefully (identity, diagnosis, and program)

Tested by not reading carefully (identity, diagnosis, and program)

2Preparing tools / media (flip sheet / poster / display) 3

The stationery and media are entirely prepared.

The stationery and media are not entirely prepared.

3 Washing hands4

Doing handwashing with proper tools and steps

Not doing handwashing with proper tools and steps

B Orientation Phase (10%)      

4 Introducing self and checking the client's identity

4

Mentioning the name and work area, and confirming the name and age of the client

Mentioning only 3 of the 4 components of nurse’s and client’s identity

5Conveying purposes and procedures 4

Correctly conveying the purpose and action steps

Conveying only the purpose or action steps

6

Delivering the contract (time, place, topic) 4

The place, type, and duration of the action are clearly stated.

The place, type, and duration of the action are unclearly stated.

7 Asking client readiness 4 Confirming correctly the client's readiness to take action

Not confirming the client’s readiness or confirming incorrectly

C Work Phase (65%)      

8

AssessingIncomplete Urination: Over the past month, how much did you feel incomplete when you urinated? 8

Asking the client in the past month how many times they feel incomplete when they urinate

Not asking the client in the past month how many times they feel incomplete when they urinate

9

Assessing Frequency: During the past month, how often did you feel you had to urinate less than 2 hours upon previous urination? 8

Asking the client how often they urinate and assessing the frequency of client's urination

Not asking the client how often they urinate and assessing the frequency of client's urination

10

Assessing Intermittence: Over the past month, how often did you feel that when you urinated, you wanted to stop and re-urinate? 8

Asking clients how often they feel that when they urinate, they want to stop and re-urinate

Not asking clients how often they feel that when they urinate, they want to stop and re-urinate

11

Assessing Urgency: throughout the past month, how often have you felt that you were unable to postpone your urge to urinate?

8

Asking the client how often they can not postpone their urge to urinate

Not asking clients how often they can't postpone urinating

12

Assessing weak urinal flow: over the past month, how often have you felt that your urine flow is weak 8

Asking the client how often they feel their urinal flow is weak

Not asking the client how often they feel their urinal flow is weak

13

Assessing Straining: Over the past month, how often did you strain to urinate? 8

Asking clients how often they strain to urinate

Not asking clients how often they strain to urinate

14

Assessing Nocturia: During the past month, how often did you have to wake up in the middle of your sleep to urinate?

8

Asking the client how often they have to wake up in the middle of their sleep to urinate

Not asking the client how often they have to wake up in the middle of their sleep to urinate

D Termination Phase (15%)      

15

Conducting evaluation (Subjective, Objective)

4

Asking the client's feelings towards the nurse's actions and conveying the results of the assessment in detail

Not asking the client's feelings towards the nurse's actions and conveying the results of the assessment in detail or only doing 1 of the 2 activities

16

Delivering RTL

3

Providing relevant follow-up plans related to the results of the assessment

Not providing relevant follow-up plans related to the results of the assessment or providing the irrelevant RTL

17 Delivering the next contract 3 Delivering the contract for the next meeting including the time, place and action

Not delivering the contract for the next meeting including time, place and action or delivering only 2 of the 3 components

18 Washing hands 3Doing handwashing with the proper tools and steps

Not doing handwashing or washing hands with the

improper tools and steps

19Documentation

4Conducting documentation upon completing the action

Not conducting documentation upon completing the action

  TOTAL 100     

OBSERVATION OF SPMQ (Short Portable Mental Status Questionnaire)

NO Activity Point Yes No

APre-Interaction Phase (10%)      

1

Verification of the therapeutic program (reading cases) 3

Tested by reading the program notes carefully (identity, diagnosis, and program)

Tested by not reading carefully (identity, diagnosis, and program)

2

Preparing tools / media (flip sheet / poster / display) 2

Thestationery and media are entirely prepared.

The stationery and media are not entirely prepared.

3Washing hands

5Doing handwashing with the proper tools and steps

Not doing handwashing with the proper tools and steps

B Orientation Phase (10%)      

4

Introducing self and checking the client's identity 2

Mentioning the name and work area, and confirming the name and age of the client

Mentioning only 3 of the 4 components of nurse’s and client’s identity

5Conveying purposes and procedures 4

Correctly conveying the purpose and action steps

Conveying only the purpose or the action steps

6Delivering contract (time, place, topic) 2

The place, type, and duration of the action are clearly stated.

The place, type, and duration of the action are unclearly stated.

7

Asking the client’s readiness

2Confirming correctly the client's readiness to take action

Not confirming the readiness or confirming incorrectly

C Work Phase (60%)      

8Asking the date? (month/year) 6

Asking the client about the date, month, andyear today

Only asking the client about the date (month/year)

9Asking what day is today

6Asking the client what day it is

Not asking the client about what day it is

10

Asking the name of the place

6

Asking the client's about the place name (the most frequently visited or the client's current place)

Not asking the client about the place name (the most frequently visited or the client’s current place)

11Asking the clients' phone number? 6

Asking the client’s phone number

Not asking the client’s phone number

13Asking the client’s date of birth (Date / Month / Year) 6

Asking the client’s date of birth (Date/Month/Year)

Only asking the client’s date or month or year of birth (2 of the 3 components)

14Asking the name of the current president 6

Asking the client about the name of the current president

Not asking the client about the name of the current president

15Asking the name of the previous president? 6

Asking the client about the name of the previous president

Not asking the client about the name of the previous president

16

Asking the client's mother's name

6

Asking the client’s mother's name

Asking the client’s mother's name

17

Asking the client to count (e.g. 5 + 6=… (Counting down 3-3 starting from 20) 6

Asking the client about how to calculate, e.g., counting down starting from 20

Not asking the client about how to calculate, e.g., counting down starting from 20

D Termination Phase (20%)      

18

Conducting evaluation (Subjective, Objective)

4

Asking the client's feelings towards the nurse's actions and conveying the results of the assessment in detail

Not asking the client's feelings towards the nurse's actions and not conveying the results of the assessment in detail or only doing 1 of the 2 activities

19

Delivering RTL

3

Providing relevant follow-up plans related to the results of the assessment

Not providing relevant follow-up plans related to the results of the assessment or providing the irrelevant RTL

20

Delivering the next contract

3

Delivering the contract for the next meeting including the time, place and action

Not delivering the contract for the next meeting including time, place and action or delivering only 2 of the 3 components

21Washing hands

5

Doing handwashing with the proper tools and steps

Not doing handwashing or washing hands with the improper tools and steps

22Documentation

5Conducting documentation upon completing the action

Not conducting documentation upon completing the action

  TOTAL 100     

OBSERVATION OF THE GERIATRIC DEPRESSION SCALE

NO Activity Point Yes No

APre-Interaction Phase (10%)      

1

Verification of the therapeutic program (reading cases) 3

Tested by reading the program notes carefully (identity, diagnosis, and program)

Tested by not reading the program notes carefully (identity, diagnosis, and program)

2

Preparing tools / media (flip sheet / poster / display) 2

The stationery and media are entirely prepared. The stationery and media are not

entirely prepared.

3 Washing hands5

Doing handwashing with proper tools and steps

Not doing handwashing with proper tools and steps

B Orientation Phase (10%)      

4Introducing self and checking the client's identity 2

Mentioning the name and work area, and confirming the name and age of the client

Mentioning only 3 of the 4 components of nurse’s and client’s identity

5Conveying purposes and procedures 4

Correctly conveying the purpose and the action steps

Conveying only the purpose or the action steps

6Delivering the contract (time, place, topic) 2

The place, type, and duration of the action are clearly stated.

The place, type, and duration of the action are unclearly stated.

7Asking the client readiness 2

Confirming correctly the client's readiness to take action

Not confirming the client’s readiness or confirming incorrectly

C Work Phase (60%)      

8Asking if the client is satisfied with their life 4

Asking the client about satisfaction in their life

Not asking clients about satisfaction in their life

9

Asking the client about their activities and interests that have been left behind 4

Asking the client about their activities and interests that have been left behind

Not asking the client about their activities and interests that have been left behind

10Asking if the client feels that their life is empty 4

Asking if the client feels that their life is empty

Not asking if the client feels that their life is empty

11

Asking whether the clientoften gets bored

4

Asking the client when they often feel bored, rarely, or never feel bored

Not asking the client when they often feel bored, rarely, or never feel bored

12Asking if the client always has enthusiasm 4

Asking if the client always has enthusiasm

Not asking if the client always has enthusiasm

13 Asking if the client 4Asking if the client worries

Not asking if the client worries

worriesthat something will happen to them

that something will happen to them

that something will happen to them

14Asking if the client feels happy everyday 4

Asking if the client feels happy everyday

Not asking if the client feels happy every day

15Asking if the client feels bored 4

Asking if the clientfeels bored Not asking if the client feels bored

16

Asking if the client would rather stay home at night than going to do something new? 4

Asking if the client would rather stay home at night than going to do something new

Not asking if the client would rather stay home at night than going to do something new

17

Asking if the client feels that they have more problems with their memory than others 4

Asking if the client feels that they have more problems with their memory than others

Not asking if the client feels that they have more problems with their memory than others

18

Asking if the client feels unmeaningful at this time

4

Asking the client whether their life is pleasant at this time

Not asking the client whether their lifeis pleasant at this time

19

Asking if the client feels full of energy at this time

4

Asking the client whether they feel useless in life and why

Not asking the client whether they feel useless in life and why

20Asking whether the client feels hopeless at this time 4

Asking whether the client feels full of energy at this time

Not asking the client whether they feel full of energy at this time

21

Asking if the client thinks many people are better than them 4

Asking the client whether they feel hopeless in their life

Not asking the client whether they feel hopeless in their life

22

Asking the client if they think many people are better than them 4

Asking the client if they think there are many people who are better than them

Not asking the client if they think there are many people who are better than them

D Termination Phase (20%)      

18

Conducting evaluation (Subjective, Objective)

4

Asking the client's feelings towards the nurse's actions and conveying the results of the assessment in detail

Not asking the client's feelings towards the nurse's actions and not conveying the results of the assessment in detail or only doing 1 of the 2 activities

19 Delivering RTL 3

Providing relevant follow-up plans related to the result of the assessment

Not providing relevant follow-up plans related to the results of the assessment or providing the irrelevant RTL

20Delivering the next contract 3

Conveying the contract for the next meeting including the time, place and action

Not conveying the contract for the next meeting including time, place and action or conveying only 2 of the 3 components

21Washing hands

5

Doing handwashing with the proper tools and steps

Not doing handwashing or washing hands with the improper tools and steps

22 Documentation 5Conducting documentation upon completing the action

Not conducting documentation upon completing the action

  TOTAL 100    

OBSERVATION OF RISK OF FALLING IN ONTARIO MODIFIED STRATIFY - SYDNEY SCORING

NO Activity Point Yes No

 

  

     

APre-Interaction Phase (10%)        

  

1

Verification of the therapeutic program (reading cases)

3

Tested by reading the program notes carefully (identity, diagnosis, and program)

Tested by not reading the program notes carefully (identity, diagnosis, and program)  

 

 

2

Preparing tools / media (flip sheet / poster / display) 2

The stationery and media are entirely prepared. The stationery and

media are not entirely prepared.  

 

 

3 Washing hands5

Doing handwashing with the proper tools and steps

Not doing handwashing with the proper tools and steps  

 

 B Orientation Phase (10%)            

4 Introducing self and checking the client's identity 2

Mentioning the name and work area, and confirming the name and age of the client

Mentioning only 3 of the 4 components of nurse’s and client’s identity  

 

 

5

Conveying purposes and procedures

4

Correctly conveying the purpose and the action steps

Conveying only the purpose or the action step  

 

 6 Delivering the contract

(time, place, topic)2 The place, type, and duration

of the action are clearly The place, type, and duration of the action

     

stated. are unclearly stated.

7

Asking the client’s readiness

2

Confirming correctly the client's readiness to take action

Not confirming the client’s readiness or confirming incorrectly  

 

 C Work Phase (60%)            

8History of Falling Experience

10          

 

Asking if the client visits the hospital because they have fallen.(If not, has the client experienced falling in the past two months?)  

Inquiring about the client's falling history

Not inquiring about the client's falling history

 

 

 9 Mental Status 10          

 

Asking whether the client cannot make decisions and has memory problems?

 

Asking whether the client has a memory problem and difficulty in making decisions

Not asking whether the clienthas a memory problem and difficulty in making decisions  

 

 

 

Asking the client about the time, place,and people around them

 

Asking the client about the time, place and people around them

Only asking about 2 of 3 components(time or place or person)  

 

 

 

Asking whether the client experiences agitation (fear, uneasiness, and anxiety)

 

Asking the client whether they experience fear, uneasiness, and anxiety

Not asking the client whether they experience fear, uneasiness, and anxiety  

 

 10 Vision 10          

 

Asking if the client uses glasses?

 

Asking the client whether theyuse glasses

Not asking the client whether theyuse glasses  

 

 

 

Asking if the client has a complaint about optical problems

 

Asking whether the client has a complaint about optical problems

Not asking if the client has a complaint about optical problems  

 

 

 

Asking if the client has glaucoma? Cataract / macular degeneration?

 

Asking if the client hasa history of glaucoma? Cataract / macular degeneration

Not asking if the client has a history ofglaucoma? Cataract / macular degeneration  

 

 11 Urinary Habits 10          

 Asking the client if there

 Asking the client if there is a Not asking the client

  

 

isa changinghabit in their urination (frequency, urgency, incontinence, nocturia)

changing habit in their urination (frequency, urgency, incontinence, nocturia)

if there is a changing habit in their urination (frequency, urgency, incontinence, nocturia)

12

Transfer (from bed to chair and back to bed)

10

 

   

 

 

 

Askinghow the client moves from bed to wheelchair (by himself, bydevice, or byothers’ help)  

Askinghow the client moves from bed to wheelchair (by himself, by device, or by others’ help)

Not asking how the client moves from bed to wheelchair (by himself, by device, or by others’ help)  

 

 

13Unable to sit stably;totally need help 10

    

  

 

Asking whether the client can sit stably by himself, by the help of 1 person, or by using a wheelchair

 

Asking whether the client can sit stably by himself, by the help of 1 person, or by using a wheelchair?

Not asking whether the client can sit stably by himself, by the help of 1 person, or by using a wheelchair  

 

 D Termination Phase (20%)            

14

Conducting evaluation (Subjective, Objective)

4

Asking the client's feelings towards the nurse's actions and conveying the results of the assessment in detail

Not asking the client's feelings towards the nurse's actions and not conveying the results of the assessment in detail or only doing 1 of the 2 activities  

 

 

15

Delivering RTL

3

Providing relevant follow-up plans related to the results of the assessment

Not providing relevant follow-up plans related to the results of the assessment or providing the irrelevant RTL  

 

 

16

Delivering the next contract

3

Conveying the contract for the next meeting including time, place and action

Not conveying the contract for the next meeting including time, place and action or conveying only 2 of the 3 components  

 

 17 Washing hands 5 Doing handwashing with the Not doing      

proper tools and steps

handwashing or washing hands with the improper tools and steps

18Documentation

5

Conducting documentation upon completing the action

Not conducting documentation upon completing the action  

 

   TOTAL 100