Originality from UOIT comments

Level of consciousness, position, skin colour, facial expression, presence of distress or pain

Subjective inquiry

P

Q

R

S

T

U

Obtain temp*

Radial Pulse*will be on monitor Respirations*

BP (both arms if cardiac pt)*

02 saturation*

Assess orientation

Check pupils PERRLA

Facial expression/demeanor

Inspect anterior chest

Symmetry, skin colour & condition, edema

Shape & configuration (ribs sloping downward, symmetrical)

Costal angle (normal less than 90 degrees)

Quality of respirations

Palpate

Temperature

Masses / tenderness

Pulsations / heaves

Auscultation respirations (anterior)

Follows 5 point sequence comparing left to right, clear, good a/e bilaterally, no adventitious breath sounds

Assess chest tube/suction/tracheostomy dressing/ oxygen

Auscultate heart sounds Appropriate landmarks(APETM sequence)with diaphragm

apical rate*

Asses with bell*/ left lateral position*

Identifies where lub/dub loudest*

Listens through diastole & systole

Capillary refill (< 3 sec)

Palpate peripheral pulses

Skin temp edema

Muscle strength arms & legs

Inquires about changes in appetite and last BM

Inspect

Abdomen (contour, symmetry, scars, straie)

Auscultate

Bowel sounds starting in RLQ and proceeds to RUQ, LUQ, LLQ

Must listen for 5 second per quadrant

Acknowledge it can take up to 5 minutes to determine absence of bowel sounds

Palpation

Light palpation (1 cm using fingertips)

Deep palpation (5-8 cm using one or two hands)*

Assess urine output/size of foley*

Assess dressings*/colostomy*/ileostomy*/ileoconduit*/bruits*

Assist patient to sit at side of bed (or in high fowlers)

Assessment of posterior/lateral chest Inspect

Symmetry of chest, skin colour & condition

Alignment of spinous process

Palpate

Tenderness*, masses*

Auscultation (posterior and lateral):

General auscultation (follow 8 point sequence and 2-3 point for lateral, clear, good a/e bilaterally, no adventitious breath sounds)

Environmental Scan

Garbage removed

Call bell/bed in lowest position

Discuss normal & abnormal findings and plan for medication with facilitator

Discuss priorities of care using diagnosis, assessment findings, lab values

Determine appropriate medication to prepare

Assess patient:

Any required assessments

IV site for phlebitis/infiltration

Bag, tubing, solution, TBA, rate etc

Critical thinking

Mechanism of action

Onset/peak/duration

Side effects/adverse reactions

Compatibility/Run time (IV monograph)

Dose Calculation (pump & gravity rate)

Right Patient

Right Medication

Right Dose

Right Route

Right Time

Right Frequency

Right Reason

Right Site

Allergy check

Check MAR verification

Right Patient

Right Medication

Right Dose

Right Route

Right Time

Right Frequency

Right Reason

Right Site

Prepares accurate drug labelRight Patient

Right Medication

Right Dose

Right Route

Right Time

Right Frequency

Right Reason

Right Site

Rechecks dose calculation (pump & gravity)

Copy unique # Check unique # to patients wristband & rechecks allergy

Attach piggyback using sterile technique

Regulates rate accurately Documentation: Date/time/dose/signature Signature ProfileComments