Assessment

Question 1

Start assessment by doing what 3 things?

Answer 1

1. AAOx4? Person, place, time, situation
2. Look at Vitals
3. Pain scale? Describe pain if any,

Question 2

Starting at the head, what are three things to do?

Answer 2

1. Perrla
2. Oral/Nasal mucosa - Tubes in place? Mark down measurements
3. Any edema or skin breakdown

Question 3

After the Head, what is the next action? Three things to do.

Answer 3

• Have patient turn or turn patient to side*
  1. Listen to posterior Lungs (Starting at top left, then right, then left, then right etc..)
  2. Observe and note any skin breakdown or discoloration on back area (Shoulders, Sacrum, Heels)
  3. Check for incontinence. If needed, wipe the patient, change pads, apply barriers.

Question 4

After Posterior Side, what is the next action? What are seven things to do?

Answer 4

• Move to upper Anterior side*
  1. Listen to anterior lungs at six points.
  2. Listen to apical for one minute (s1 and s2, not any abnormalities)
  3. Listen to Bowel sounds in all four quadrants.
  4. Check radial pulses bilaterally and note strength, rate rhythm.
  5. Have patient squeeze your fingers if possible
  6. Observe for any skin breakdown, discoloration, temp changes.
  7. Observe any IVs, Dressing status, check if patent via flush.