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Before entering the room
Check outside room for signage
Assemble/prepare required equipment
Wash hands
Don PPE if required
Enter Room
N: name
O: occupation
D: description of profession
ways to identify pt
first and last name
phn
dob
id wrist band
Initial Assessment - ABCCS
airway
breathing
circulation
consciousness
safety
equipment safety check
Level of Orientation
person
time
location
situation
Assess Pain
L: location
O: onset (start and duration of pain)
T: timing (pain is constant or intermittent, change in intensity)
T: type of pain
A: associated symptoms
A: alleviating factors
R: radiation (movement of pain)
P: precipitating event (what happened b4 the pain began, cause)
Measure Vital Signs
BP
HR
O2 sat level
temp
RR: Respiration Rate
temp
Normal (oral) = 35.8ÂşC to 37.3ÂşC
thermometer
HR/ pulse
Normal resting heart rate = 60 to 100 beats per minute
RR / Respiration Rate
Normal resting respiratory rate = 10 to 20 breaths per minute
BP
average BP for an adult is 120 mmHg systolic /80 mmHg diastolic
O2 sat level
healthy patient will have an SpO2 of ≥ 97%
measured by a pulse oximeter sensor attached to the patient’s finger or earlobe
Focused Assessment
head to toe assessment
to provide information on one specific concern or body system the patient is experiencing difficulty with or system the assessor requires further information.Â
final check b4 leaving room
ask pt pain
ask pt for any other needs
check if call bell or other necessary items in reach
put bed in lowest position, brakes on, rails up
when leaving room
collect supplies
hand hygiene
doff
don gloves and clean equip
report and document
Accurate and timely documentation and reporting promote patient safety
EEL(BCIT), AH(CI)
Age to ask for a chance of pregnancy
11-55
tachycardia
over 100 beats /min
bradycardia
lower 60 beats/min
where should BP be taken
on the left side for a true reading since the heart is closest to the left
when is O2 supplied?
for SO2 less than 92%
hypoxia
a condition where a patient has insufficient oxygen to meet the body's needs
all O2 medications need prescription but hypoxia is considered an emergency situation
steps of applying nasal prongs
Determine need for supplemental oxygen
Check physician orders or oxygen therapy protocol
Hand Hygiene and gather supplies
assist PT into fowlers
attach NP to wall outlet or oxygen tank, ensure it is attached to the O2 and NOT air outlet, check that its working
Hold NP with curved prongs facing downward.
Place nasal prongs into nares
Loop the tubing up and over the ears
Adjust plastic slide under PT chin for stability and ensure comfort
Assess and observe client’s response to therapy after 5 minutes, titrate O2 levels up until above 92% (normal range), for higher level of O2 change to simple face mask
Oral pharyngeal Suctioning
process in removing pool of secretion to prevent aspiration
EX: yankauer catheter, suction tubing, and wall or portable suction
When to use Oral pharyngeal Suctioning
Vomiting in patients who can not change positions
 Audible rattling or gurgling sounds coming from the patient's throat
 Signs of respiratory distress
vertigo
disturbance of the equilibrium mechanism in the inner ear
Unsteadiness and disturbance in coordination
Nausea, which may lead to vomiting
Rapid eye movement (nystagmus)
syncope
fainting
lethargy
abnormal drowsiness
pruritus
Itchiness