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Med Surge 1 > Shift Assessment > Flashcards

Shift Assessment Flashcards

1
Q

Introduction

A

Name, I’m your nurse for the shift

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2
Q

Hand hygiene

A

Sanitize hands

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3
Q

Patient Verification

A

Ask for name and birthday, check ID band

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4
Q

Basic vital signs

A

BP, HR, RR, Temp, Pain, Pulse ox

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5
Q

Explain assessment

A

Quick shift assessment, 10-15 minutes, to go over main body functions.

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6
Q

Review chart

A

Review Mar, ask about allergies, ask about any concerns

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7
Q

Past medical history

A

Review chart

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8
Q

Overall appearance

A

Assess how they look

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9
Q

Obtains Glascow Coma scale

A

Follow hospital protocol

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10
Q

Assess level of conciousness

A

Alert and oriented? Ask who they are, where they are, why they’re there, and what month and year it is.

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11
Q

Note slurred speech or facial droop

A

As you are speaking with the patient, verbalize this.

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12
Q

Assess pupils

A

Shine pen light in each eye, see if pupils constrict

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13
Q

Assess for headaches and dizziness

A

Ask pt if they have any headaches or dizziness

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14
Q

Assess for language barrier

A

Note if pt speaks another language, aphasia

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15
Q

Inspect face, head

A

Assess for symmetry

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16
Q

Inspect external nose, lips, oral mucosa

A

Assess for symmetry, check nose for drainage, ask pt to open mouth, shine pen light inside.

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17
Q

Ask pt if they were dentures

A
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18
Q

Ask pt if they have any problems swallowing or chewing

A
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19
Q

Assess external ears

A

Look for drainage

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20
Q

Inspect neck, trachea, thyroid

A

Ask pt to look up.

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21
Q

Examine for JVD

A

From right side of pt, ask pt to turn head to the lift

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22
Q

Check for grip strength

A

Hold pt’s hands and have them squeeze your hands and pull.

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23
Q

Ask if they can move arms fully

A

Have pt move arms out to the side, then up straight.

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24
Q

Assess skin color, condition, temperature

A

Verbalize this

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25
Q

Assess for tenting

A

Pinch skin

26
Q

Assess skin for brusies, lesions, wounds, rashes, other abnormalities

A

Throughout the assesment

27
Q

Assess respiratory pattern

A
28
Q

Auscultate breath sounds

A

Underneath gown, anterior and posterior

29
Q

Evaluates use of accessory muscles

A

Note if pt uses while breathing

30
Q

Notes chest excursion is symmetrical

A

Verbalize this

31
Q

Ask about any cough

A

If so, ask amount, color, consistency

32
Q

Assess for shortness of breath

A

Ask pt

33
Q

Assess position

A

If it impacts breathing

34
Q

Listen to heart sounds

A

S1, S2, murmurs, gallops

35
Q

Assess cardiac rhythm, regularity, rhythm tolerance

A
36
Q

Assess for chest pain

A

Ask pt

37
Q

Assess for edema

A

Bilateral upper extremities

38
Q

Assess capillary refill

A

One fingernail on each hand

39
Q

Assess radial pulses

A

Strength

40
Q

Assess IV site(s)

A

If applicable

41
Q

Inspects abdomen

A

Soft, non tender, non distended

42
Q

Auscultates bowel sounds

A

Each quadrant

43
Q

Palpates abdomen

A

Asks if any pain or tenderness

44
Q

Assess bowel movements

A

Ask pt when last bm was

45
Q

Assess for GI complications

A

Ask pt if experiencing any nausea, vomiting, constipation, diarrhea

46
Q

Assess for urinary problems

A

Ask if any burning, pain, frequency, color, odor

47
Q

Assess for continence of pt

A

Note any briefs

48
Q

Assess and urinary diversions

A

Catheters, ureterostomy

48
Q

Assess for Lower extremity movement

A

Ask pt

48
Q

Assess for edema

A

Lower extremities

48
Q

Ask pt about gait/balance

A

Ask pt if they can walk, only if appropriate

49
Q

Assess pulses

A

Dorsalis pedis, posterior tibial

50
Q

Capillary refill

A

One toenail on each foot

51
Q

Assess foot movement

A

Against resistance, have pt push down on hands, have them pull back against hands

52
Q

Put bed in lowest postion

A

Adjust to pt prefrence too

53
Q

Call light within reach

A
54
Q

Make space clutter free

A

bedside table

55
Q

Personal belongings within reach

A

As applicable

56
Q

Grip socks on pt

A

as applicable

57
Q

Conclude exam

A

Thank pt for their time, ask pt if they need anything before you leave

Med Surge 1 (1 decks)

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