WEEK 1: OPQRSTU, SAMPLE, SOMETEAMS & Bedside Safety Check

What does the O in OPQRSTU for?

Onset
- When did this first occur?
- Was this sudden, gradual, or an ongoing problem?
- Has this happened before?

What does the P in OPQRST stand for?

Precipitation or Palliation
- Do you believe something precipitated the event or brought this on? Describe
- Is there anything that makes it better or helps it to "go away" (palliation)

What does the Q in OPQRST mean?

Quality
- Describe the problem or symptom in detail (describe the pain)
- Can you describe it to me? (dull, sharp, crushing, burning, constant, throbbing)

What does the R in OPQRST stand for?

Region/Radiation?
-Where exactly is it? (Pain in the shoulder radiation to the jaw)
-Does it seem to spread anywhere else? (numbness in L arm, then 10 mins later numbness began in the L leg)

What does the "S" in OPQRST stand for?

Severity
-If zero is NO pain and 10 is the worse pain you can imagine, what number is your pain?

What does the T in OPQRST stand for?

Time
- Is there a pattern you have noticed? Pattern of onset/resolution or a pattern of change?
-When did the problem start?
-Has it changed since it started, better/worse?

What does U in OPQRSTU stand for?

Understanding
- What do you think causes this? (This is how the patient understands the events)
- Is this similar to something that has happened before?

What does the S in SAMPLE stand for?

signs and symptoms

What does the A in SAMPLE stand for?

allergies

What does M in SAMPLE stand for?

medications

What does P in SAMPLE stand for?

past medical history

What does L in SAMPLE stand for?

Last oral intake.
-When did you eat or drink last?
-What did you eat or drink?

What does E in SAMPLE stand for?

Events leading up to the incident

What does the first S in SOMETEAMS stand for?

Symmetry: Is the face and body symmetrical?

What does the O in SOMETEAMS stand for?

Old: Do they look their age?

What does the first M in SOMETEAMS stand for?

Mental Acuity: Is the client alert, confused, agitated or inattentive? Current activity appropriate?

What does the first E in SOMETEAMS stand for?

Expression: Does the client appear ill, in pain or anxious?

What does the T in SOMETEAMS stand for?

Trunk: Is the client stocky, lean, obese or barrel chested?

What does the second E in SOMETEAMS stand for?

Extremities: Color, skin condition, deformity in joints?

What does the A in SOMETEAMS stand for?

Appearance: Is the client appropriately clean and dressed?

What does the M in SOMETEAMS stand for?

Movement: Posture, gait, and coordination appear normal?

What does the second S in SOMETEAMS stand for?

Speech: Is his speech relaxed, clear, strong, comprehensible, and appropriate? Do they sound stressed?

What should be the first thing you look for during BEDSIDE SAFETY CHECK?

1.Any obvious sign of distress

During the BEDSIDE SAFETY CHECK, what are somethings you should be checking about the patient and the surroundings?

- Level of consciousness (know baseline confusion/wandering, hearing/vision/speech impairment)
-Patient environment (clear of hazards) - e.g. water on floor, fire, walker close enough, etc.
- Patient's bed: in lowest position, brakes on, safe amount of side rails up if needed, no tripping or slipping hazards around
- Tubes/IV's/Dressings intact and correct. E.g. oxygen on at correct rate, dressing visibly intact

During a BEDSIDE SAFETY CHECK, what should you check with regards to forms?

- ACP status (should be part of the Nurse's worksheet)
- Allergies (on arm band and in chart and MAR)

True or False: during a BEDSIDE SAFETY CHECK the nurse should check that the call bell is within reach

True

True or False: During a BEDSIDE SAFETY CHECK, the nurse should not address immediate safety concerns and should focus on fixing the bedding

False, the nurse should make sure the patient is safe and if they are not, that there is a plan for fixing any problems that are cause danger

When should OPQRSTU be used?

When a patient is describing their SUBJECTIVE FEELINGS or SYMPTOMS, during the discussion about how the person is feeling

When should a nurse use SAMPLE?

Usually this is used after asking OPQRSTU

True or False: A nurse should be checking for SOMETEAMS as she is walking in the room of the patient or after introducing themselves

True, a nurse should be using SOMETEAMS to check on the patients status and if there is anything that is concerning