Head to toe

Question 1

CNS
- Central nervous system and neurological assessments

Answer 1

• GCS
• CAM (delirium)
• CPOT or appropriate pain assessment
• RASS (sedation score)
• NIHSS (stroke scale)
• Plan sedation holds to assess true neurology

Question 2

RESP
- Respiratory, gas or ventilatory assessments

Answer 2

• Mode of ventilation
• Comprehensive respiratory assessment
• Observe and compare chest x-rays
• Observe gas trends
• Review means of oxygenation and titrate down if able

Question 3

CVS
- Cardiovascular and circulatory assessments

Answer 3

• 12 lead ECG (compare to historical ECGs)
• Review cardiac monitor and parameters
• Review Hb
• Review pacing/pacing wires
• Zero arterial line and review blood pressure targets (non-invasive blood pressure to verify accuracy of art line)
• Circulation observations to all limbs
• Puncture site observations

Question 4

GIT
- Gastrointestinal tract/glucose, nutrition and bowel assessments

Answer 4

• Food chart and nutritional assessment (review feeds or TPN)
• Review bowel chart and prescribed aperients
• Attend BGL and review glucose management plan

Question 5

Renal
- Renal fluid and urinary assessments

Answer 5

• Review IDC
• Fluid assessment including updating of fluid balance
• Review dialysis if on continuous renal replacement therapy
• Review electrolytes

Question 6

Integumentary
- Skin integrity, temperature, hygiene, wound assessments

Answer 6

• Review hygiene status and plan personal care
• Pressure injury assessments (waterlow or PIRA)
• Wound assessments and dressing changes as required

Question 7

Lines/access
- Drain, access or invasive device

Answer 7

• Review all drains for patency, safe securement and output trends, as well as removal orders
• Review all access points for patency, ensure they are clamped or hep locked as required. Schedule clave changes or removal as required
• Other invasive device assessments i.e. NGT

Question 8

Drugs
- Medication assessments

Answer 8

• Review all continuous infusions and consider polypharmacy, interactions and need
• Replace/refill infusions accordingly
• Minimise pharmacotherapy where able in the interest of de-internationalisation
• Schedule other charted medications

Question 9

Social
- Psychosocial assessments

Answer 9

• MSE or other well-being assessments
• Review the carer, family or loved one communication plan

Question 10

FAST HUGS IN BED Please

Answer 10

• Fluid therapy and feeding
• Analgesia, Antiemetics and ADT
• Sedation and Spontaneous breathing trial
• Thromboprophylaxis, Tetanus prophylaxis
• Head up position
• Ulcer prophylaxis
• Glucose control
• Skin/eye care and suctioning
• Indwelling catheters
• Nasogastric tube
• Bowel care
• Environment (temperature control, appropriate surroundings in delirium)
• De-escalation (end of life issues, treatments no longer needed) and Delirium
• Psychosocial support