Beruflich Dokumente
Kultur Dokumente
Focused
System
Assessment
Requirements
for
NURS
311
&
NURS
333
Environment
• Suction:
setup
and
function
• Oxygen:
verifies
presence
of
O2,
Verifies
rate
of
flow
&
device
• Bed:
lifts
to
safe
working
height,
lowers
when
leaving
room
• IV:
rate,
solution,
site
• Foleys/drains:
verifies
presence
Communication
§ Demonstrate
communication
with
their
patient
and
partner
that
is:
o Respectful
o Professional
o Timely
o Clear
§ Recognize
possible
missed
patient
assessments
/
interventions
and
communicate
these
during
the
scenario
§ Document
in
an
accurate
and
timely
manner
on
appropriate
forms,
each
lab
§ Focus
on
patient
priorities
throughout
each
scenario
§ SBAR:
Detailed,
accurate,
clear
CNS
• General
appearance
• Behavior
• Level
of
consciousness,
GCS
score,
Orientation
X3
• PERRLA
• Dizziness,
visual
disturbances,
tremors*
• Body
position/posture/gait*
• Pain
or
headache:
PQRSTU
CVS
• BP
• Distal
Pules(s):
rate,
rhythm,
quality
(0,
1+,
2+,
3+)
(radial)*
• Heart
Sounds:
S1S2,
Apical
pulse
(rate,
rhythm,
quality)
• Extra
heart
sounds,
murmurs
• Chest
pain:
PQRSTU
PVS
• Cap
refill
&
peripheral
pulses
(dorsalis
pedis
or
posterior
tibialis
OR
related
pulses)*
• Color,
warmth,
movement,
sensation
of
all
extremities*
• Edema-‐
location,
pitting,
non-‐pitting*
• Pain
to
extremities:
PQRSTU
GI
• Abdomen
contour
(flat,
round,
protuberant),
soft/firm,
distention
• Bowel
sounds
x4
(start
in
RLQ)
• N/V/BM
(frequency,
intensity)
• Nutritional
status
(eating/drinking,
current
diet?
Tolerating
diet?)
• Pain
to
abdomen/GI:
PQRSTU
GU
• Urine
(amount,
appearance,
odor,
frequency
or
urgency)
• Presence
of
catheters
or
drainage
• Pain
to
related
to
voiding/GU:
PQRSTU
MSK
• ROM,
Movement
and
strength
of
extremities*
• Circulation,
sensation,
warmth
of
affected
extremity*
• Pain
to
extremities:
PQRSTU
INTEG:
• General
skin
appearance
(color,
hair
distribution,
redness)
• Pressure
points
• Wounds-‐
assess
using
REEDA/MEASURE
• Pain
related
to
skin/wounds:
PQRSTU