bedside assessment questions and answers well illustrated.

bedside assessment questions and answers well illustrated. objectives of bedside assessment - correct n hospitalized pt medical history perform problem based physical assessment on hospitalized pt recognize normal/abnormal what is up with my pt - correct 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 - correct signs: correct?? high risk for falls, isolation precaustions, latex allergies? meet and greet pt - correct eye contact introduce yourself acknowledge patient first focus questions on info recieved in report patient contact guidelines - correct hands, verify armband, equiptment set up, anything missing or incorrect general appearance - correct l expression, body postion, level of consciousness (A/O x 3), skin color, nutritional status, speech, hearing, hygeine measurement - correct signs pulse oximetry: 92% is goal copd: 88-92% so they can keep drive to breath pain level and tolerance pain reassessment - correct s re-assess pain and document new #/10 give meds time to work general rule is to reassess in 30 min IV reassessment - correct n 15 min (intravenous) PO - correct mouth within 1 hour neuro - correct li, motor response, verbal resonse perrla muscle strength (grips hands, push your feet into my palms) ptosis (facial droop) sensation if indicated communication swallowing ability if patient isn't NOP (nothing by mouth : latin) respiratory - correct n (filtered correctly, actually on, oxygen percentage patient is recieveing:FiO2) resp effort ascultate cough: check for mucose incentive spirometer: exhale, then breath in using mouthpiece and hold cardio - correct gown, inspect cap refill and edema take note: fluid overload, dehydration, iv fluids may need to be adjusted by providor skin - correct n risk assessment inspect: don't forget the iv site braden risk assessment - correct answers.Tool used by nurses to measure risk for pressure ulcers in patients. Score range 6-23. Low indicates higher risk for pressure ulcer. 18 is cut off score for onset of pressure ulcer risk. npo - correct ng by mouth abdomen notes - correct was the last time you voided today after surgery, usually void w/in 6 hrs urine color foley catheter activity - correct ity orders: Bed rest? anti blood clot devices: ideally worn 22 of 24 hrs a day complete fall risk scales ambulatory brp - correct oom privilages