objectives of bedside assessment – obtain hospitalized pt medical history
perform problem based physical assessment on hospitalized pt
recognize normal/abnormal
what is up with my pt – get the scoop on your pt
obtain from: report from off going nurse, what was the last few hours like, from chart:
last few days especially
outside pt room – note signs: correct??
high risk for falls, isolation precaustions, latex allergies?
meet and greet pt – make eye contact
introduce yourself
acknowledge patient first
focus questions on info recieved in report
patient contact guidelines – wash hands, verify armband, equiptment set up, anything
missing or incorrect
general appearance – facial expression, body postion, level of consciousness (A/O x
3), skin color, nutritional status, speech, hearing, hygeine
measurement – vital signs
pulse oximetry: >92% is goal
copd: 88-92% so they can keep drive to breath
pain level and tolerance
pain reassessment – always re-assess pain and document new #/10
give meds time to work
general rule is to reassess in 30 min
IV reassessment – within 15 min (intravenous)
PO – by mouth within 1 hour
neuro – stimuli, motor response, verbal resonse
perrla
muscle strength (grips hands, push your feet into my palms)
ptosis (facial droop)
sensation if indicated