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Before You Start
Close curtain
Hand Hygiene
Patient Identifiers
Adjust Bed Height
Put down Side Rail
Focused Assessment
Ask about Breathing
Elevate HOB
Follow up about breathing > O2 is low.
Apply Oxygen
Gather Subjective Data
Ask about cough
Ask about fatigue
Head and Neck
Inspect > Skin > unexpected
Rash on neck > medical ruler > Unexpected
Anterior Chest
Inspect > Respiratory Status > Unexpected
Inspect > Skin > Expected
Inspect > Turgor > Expected
Auscultate > stethoscope > Unexpected
Posterior Chest
Inspect > Skin > Expected
Auscultate > stethoscope > Unexpected
Rest of Body Inspection
Upper Extremities > Check O2 Levels > Oximeter > Expected
Upper Extremities > inspect > Skin > UNexpected
Abdomen > inspect > Skin > Expected
Lower Extremities > inspect > Skin > Expected
Lower Extremities > inspect > edema > Expected
Before you Leave
Raise side rail
Lower bed
Hand Hygiene
Open curtain