Week 2 - Patient Assessment

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) = 35.8ºC to 37.3ºC

• 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. 

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

1. Determine need for supplemental oxygen

2. Check physician orders or oxygen therapy protocol

3. Hand Hygiene and gather supplies

4. assist PT into fowlers

5. attach NP to wall outlet or oxygen tank, ensure it is attached to the O2 and NOT air outlet, check that its working

6. Hold NP with curved prongs facing downward.

7. Place nasal prongs into nares

8. Loop the tubing up and over the ears

9. Adjust plastic slide under PT chin for stability and ensure comfort

10. 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

1. Vomiting in patients who can not change positions

2.  Audible rattling or gurgling sounds coming from the patient's throat

3.  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