Shared Flashcard Set

Details

Observation Check-Off
Observation Check-Off
23
Nursing
Undergraduate 2
10/14/2009

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Cards

Term
Step 1
Definition
Gathers exam equipment. (watch,penlight,stethoscope,b/p cuff,note pad and black pen)
Term
Step 2
Definition
Perform WIPIE-A
Term
Step 3
Definition
Obtain Ht and Wt (Verbalize)
Term
Step 4
Definition
Place patient in appropriate position.
Term
Step 5
Definition
Takes Vital Signs (B/P,Pulse,Temp,Resp) (Verbalize)
Term
Step 6
Definition
Do overall view of pt. Any distress or pain? Any O2? How many Liters going?
Term
Step 7
Definition
Rate their pain.
Term
Step 8
Definition
Do they have an IV? Where is it located? Is dressing intact? Is IV heplocked or are fluids infusing? Check infusion rate.
Term
Step 9
Definition
Alert and oriented x3 (person,place,& time)
Term
Step 10
Definition
PERRLA (Pupils Equal, Round, & Reactive to Light and Accommodation)
Term
Step 11
Definition
Check bilateral grips. Are they equal in strength?
Term
Step 12
Definition
Any hearing problems? (HOH, hearing aids)
Term
Step 13
Definition
Any visual problems? (glasses, contacts)
Term
Step 14
Definition
Neck: Is neck sore,stiff, or swollen?
Term
Step 15
Definition
Lungs: Auscultate lung sounds. Listen to posterior & anterior chest wall.
Term
Step 16
Definition
Heart: Auscultate heart sounds. Listen & count apical heart rate. Note any irregular rhythm or sound. 
Term
Step 17
Definition
Skin: Is sensation intact? Is skin warm,pink, & dry?
Term
Step 18
Definition
Abdomen:  Listen in all 4 quadrants. Do you hear bowel sounds? Are they hyperactive or hypoactive? When was last BM(formed or diarrhea)? Colostomy?
Term
Step 19
Definition
Urinary: Are they voiding ok? Any burning, urgency, or hematuria? Do they have a foley cath? Note color, amount, or any odor.
Term
Step 20
Definition
Leg assessment, ROM; Any swelling in lower extremities?
Term
Step 21
Definition
Feet: Check for pedal pulses, capillary refill, & any ulcerations.
Term
Step 22
Definition
Posterior of patient: Check for any skin breakdown.
Term
Step 23
Definition
Side rails up x2. Call light in reach. Will coninue to monitor closely.
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