Shift Assessment

Question 1

Introduction

Answer 1

Name, I’m your nurse for the shift

Question 2

Hand hygiene

Answer 2

Sanitize hands

Question 3

Patient Verification

Answer 3

Ask for name and birthday, check ID band

Question 4

Basic vital signs

Answer 4

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

Question 5

Explain assessment

Answer 5

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

Question 6

Review chart

Answer 6

Review Mar, ask about allergies, ask about any concerns

Question 7

Past medical history

Answer 7

Review chart

Question 8

Overall appearance

Answer 8

Assess how they look

Question 9

Obtains Glascow Coma scale

Answer 9

Follow hospital protocol

Question 10

Assess level of conciousness

Answer 10

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

Question 11

Note slurred speech or facial droop

Answer 11

As you are speaking with the patient, verbalize this.

Question 12

Assess pupils

Answer 12

Shine pen light in each eye, see if pupils constrict

Question 13

Assess for headaches and dizziness

Answer 13

Ask pt if they have any headaches or dizziness

Question 14

Assess for language barrier

Answer 14

Note if pt speaks another language, aphasia

Question 15

Inspect face, head

Answer 15

Assess for symmetry

Question 16

Inspect external nose, lips, oral mucosa

Answer 16

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

Question 17

Ask pt if they were dentures

Question 18

Ask pt if they have any problems swallowing or chewing

Question 19

Assess external ears

Answer 19

Look for drainage

Question 20

Inspect neck, trachea, thyroid

Answer 20

Ask pt to look up.

Question 21

Examine for JVD

Answer 21

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

Question 22

Check for grip strength

Answer 22

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

Question 23

Ask if they can move arms fully

Answer 23

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

Question 24

Assess skin color, condition, temperature

Answer 24

Verbalize this

Question 25

Assess for tenting

Answer 25

Pinch skin

Question 26

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

Answer 26

Throughout the assesment

Question 27

Assess respiratory pattern

Question 28

Auscultate breath sounds

Answer 28

Underneath gown, anterior and posterior

Question 29

Evaluates use of accessory muscles

Answer 29

Note if pt uses while breathing

Question 30

Notes chest excursion is symmetrical

Answer 30

Verbalize this

Question 31

Ask about any cough

Answer 31

If so, ask amount, color, consistency

Question 32

Assess for shortness of breath

Answer 32

Ask pt

Question 33

Assess position

Answer 33

If it impacts breathing

Question 34

Listen to heart sounds

Answer 34

S1, S2, murmurs, gallops

Question 35

Assess cardiac rhythm, regularity, rhythm tolerance

Question 36

Assess for chest pain

Answer 36

Ask pt

Question 37

Assess for edema

Answer 37

Bilateral upper extremities

Question 38

Assess capillary refill

Answer 38

One fingernail on each hand

Question 39

Assess radial pulses

Answer 39

Strength

Question 40

Assess IV site(s)

Answer 40

If applicable

Question 41

Inspects abdomen

Answer 41

Soft, non tender, non distended

Question 42

Auscultates bowel sounds

Answer 42

Each quadrant

Question 43

Palpates abdomen

Answer 43

Asks if any pain or tenderness

Question 44

Assess bowel movements

Answer 44

Ask pt when last bm was

Question 45

Assess for GI complications

Answer 45

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

Question 46

Assess for urinary problems

Answer 46

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

Question 47

Assess for continence of pt

Answer 47

Note any briefs

Question 48

Assess and urinary diversions

Answer 48

Catheters, ureterostomy

Question 48

Assess for Lower extremity movement

Answer 48

Ask pt

Question 48

Assess for edema

Answer 48

Lower extremities

Question 48

Ask pt about gait/balance

Answer 48

Ask pt if they can walk, only if appropriate

Question 49

Assess pulses

Answer 49

Dorsalis pedis, posterior tibial

Question 50

Capillary refill

Answer 50

One toenail on each foot

Question 51

Assess foot movement

Answer 51

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

Question 52

Put bed in lowest postion

Answer 52

Adjust to pt prefrence too

Question 53

Call light within reach

Question 54

Make space clutter free

Answer 54

bedside table

Question 55

Personal belongings within reach

Answer 55

As applicable

Question 56

Grip socks on pt

Answer 56

as applicable

Question 57

Conclude exam

Answer 57

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