Nursing notes Flashcards
1
Q
Airway
A
- patent
- maintaining own airway
2
Q
Breathing
A
- Respiratory rate
- Oxygen saturation
- type of air - Room air
- Nil signs of respiratory distress
- speaking - full sentences, words
3
Q
Circulation
A
- HR - explain - regular
- BP
- capillary refill
- Perfused peripheral skin
- temperature
- pulses
4
Q
Disability
A
- alert and orientated (O + A)
- Transfer - how they are moved
- Mobility - how they get around (anything they use)
- Pain - nil complaints of pain
5
Q
Exposure
A
- Waterlow
- SSKIN
- Surface
- Skin - intact or not intact
- Keep moving - how are they being moved
- Incontinent or continent - can they get to the bathroom
- Nutrition - diet
6
Q
Fluid
A
- Diet - tolerating well
- continent - can they hold it
- Bowel open date
7
Q
Glucose
A
- do they need insulin - how many times a day
- BGL
