Bedside Assessment and Electronic Documentation (Final)

Question 1

Hospital Setting Requirements

Answer 1

some measurements like daily weight, abdominal girth and limb circumference must be consistently measured

Question 2

Health History Sequence on your way to the room

Answer 2

note and verify necessary markers of flags are in place at doorway regarding such conditions as isolation precautions, latex allergies or fall precautions

Question 3

Once in the room…

Answer 3

1. hand hygiene
2. introduce yourself (AIDET)
3. make direct eye contact and ask Q’s relative to overall status and pain
4. refer to what you heard from previous shift in process of questioning
5. assess for pain/provide comfort

Question 4

Nutritional status

Answer 4

weight appears in healthy range, even fat distribution, hydration appears healthy

Question 5

Pain Meds

Answer 5

if pain med is given, note response in 15 min. for IV administration or within 1 hr for oral

Question 6

Neurological System

Answer 6

eyes open spontaneously to name
motor response strong and bilateral
verbal response makes sense/clear and articulate
pupil size in mm and r/l reaction
any ptosis, facial droop
sensation
communication
ability to swallow

Question 7

Respiratory System

Answer 7

oxygen by mask, nasal prongs, check fitting
note FiO2
respiratory effort
ask patient to cough and deep breath, note presence of mucus
incentive spirometer usage

Question 8

Doppler Imaging

Answer 8

be prepared to assess pulses in LE if you can’t find them by palpation

Question 9

Skin

Answer 9

complete any standardized scales used to quantify risk for skin breakdown
verify that any air loss or pressure loss surfaces being used are properly applied and operated at correct setting

Question 10

GI

Answer 10

Foley catheter: check color, quantity, clarity and amount with each VS check
if output is below expected value, perform a bladder scan according to agency protocol

Question 11

Activity

Answer 11

note activity order, if pt is on bed rest HOB should be elevated
note if SCDs or TEDs are ordered and follow protocol
if ambulatory, assist pt to sitting level and move to chair
note any assistance needed and ability to transfer

Question 12

Findings that require immediate assistance

Answer 12

• BP >160 systolic or <90
• temp <96° or >100° F
• SpO2 <92%
• urine output <30 mL/hr or <240 mL/8hrs
• dark amber/bloody urine except for urology patients
• postoperative n/v
• sudden restlessness or anxiety

Question 13

EHR

Answer 13

comprehensive record of pt info and relevant clinical data (standard of care)
don’t include billing and scheduling systems but focus on pt info

Legislation HITECH Act
21st Century Cares Act

Question 14

Patient Safety

Answer 14

use of computer physics order entry (CPOE) has decreased transcription and prescribing orders
bar code scanners usage for med admin and built in checklists to help maintain safety