• Check for flags or markers at doorway or over bed
• Introduce yourself
• Perform hand hygiene
• Offer water 
• Check name band, ask for 2 forms of identification
• Raise the bed to appropriate working height

• Isolation precautions, latex/other allergies, fall precautions
• “There are no flags present.” If there are flags present, say what they mean and how you would alter your care for the patient.

•Hi, I’m Emma and I’m going to be your student nurse for today under the supervision of my clinical instructor. How have you been feeling today?

•Are you experiencing any pain?

•How did you spend the last shift?

•note the physical data this gives you:

1) state if the person is able to hear, follow directions, cross the midline, and especially the ability to swallow. 2) If the patient is not able to swallow, state what you would do and not do

•“Would you like some water?” “I noticed that the patient heard me when I asked them for water. I also noticed that they did not struggle with swallowing and that they were able to cross their midline to reach the glass”

1- Assess facial expression and describe normal findings

2- Assess body position and describe normal findings

3- Assess level of consciousness and orientation

4- Assess skin color and describe normal findings

5- Assess nutritional status and describe normal findings

6- Assess speech and describe normal findings

7- Assess hearing and describe normal findings

8- Assess Personal Hygiene and describe normal findings

• “Facial expression is appropriate to the situation, and facial features are symmetric with movement. No ptosis (eyelid drooping) and no facial drooping.”

•Symmetric with movement/no signs of acute distress or grimace

•Immobile, mask-like, asymmetric drooping

•“Body position is relaxed and comfortable.”

•Sits comfortably in bed or chair , arms relaxed at side, head toward examiner

•Tripod, sitting straight up, resisting laying down, fetal position

• Describe the following levels of consciousness:

-Alert- awake or readily aroused, oriented, fully aware

-Lethargic- not fully alert, drifts off to sleep when not stimulated, drowsy

-Obtunded- difficult to arouse, mumbled/monosyllabic speech, needs constant stim.

-Stupor- spontaneously unconscious, responds to vigorous shaking/pain, groan/reflex

-Coma- completely unconscious, no response to internal or external stimuli

• To assess orientation, ask the person if they know their name, where they are, and what time it is (day of the week, month, year).

• “Person is alert and oriented, attentive to my questions and responds appropriately.”

•“Patient has an even skin tone, pinkish tan in color which is consistent with racial heritage. No lesions are present.”

•Even-pigmentation, intact, no obvious lesions (pink-tan, warm, smooth, dry)

•Pallor, cyanosis, jaundice, erythema, lesions

•“Weight appears in healthy range, even fat distribution. I checked the chart. Nutritional assessment is within normal limits (appetite and hydration are good). Patient is on a regular diet with no nausea, bloating, diarrhea, or vomiting present with current diet. They are not at risk for nutritional deficit.”

•Within normal range for height and body build, even fat distribution

•Cachectic, emaciated, simple obese(even), centripetal (truncal) obesity

•“Speech articulation is clear and understandable, pattern is fluent and even, and the content is appropriate. The patient communicates in prevailing language (English).” (with or without interpreter, must note this).

•Articulation clear and understandable, even paced, appropriate
•Dysarthria(voice/ hoarse or whispered), dysphagia(articulation/ distorted sounds) aphasia ( language comprehension), speech defect, monotone, garbled

• “Responses and facial expression consistent with what I have said. Person can hear on both left and ride sides.”

•“The patient is clean and groomed.”

•This is noted by the appearance of the patient and their apparent ability to attend to hair, makeup, shaving, etc.

•Clean and groomed appropriately for age, occupation, social group
•Irregular hygiene behaviors (not shaving/no makeup in someone who does)

1-Assess temperature and describe normal range

2-Assess pulse and describe normal range

3-Assess respirations and describe normal range

4-Assess blood pressure and describe average blood pressure for young adult

5-Assess oxygen saturation and describe normal range

6-Assess patient’s pain

7-Pain re-assessment

•“I am going to take your temperature. I’m just going to stick the thermometer under your tongue, until it beeps.”

•Hold thermometer under sublingual pocket 3-4 minutes (afebrile) or 8 minutes (febrile). Normal range is 96.4 to 99.1 degrees F. Normal *oral* is 98.6 degrees F.

•"Temperature is ___ degrees Fahrenheit. Normal oral reading is 98.6 degrees F, and normal temperature range is 96.4 to 99.1 degrees.”

•“I am going to take your heart rate by pressing down on your wrist.”

•THREE THINGS—Rate, Rhythm, Force.

-Rate: Palpate the radial pulse for 30 seconds (first beat = 0). Multiply the rate you get by 2 to get the beats per minute. Normal range is 50 to 90 beats per minute. Less than 50 bpm is bradycardia, and more than 100 is tachycardia.

-Rhythm: regular/irregular.

-Force: 0 absent, 1+ weak/thread, 2+ Normal, 3+ full/bounding.

•"Heart rate is 78, rhythm is regular, and force is 2+ (normal).”

•Without telling patient, watch respirations after calculating heart rate. If the respirations are regular, count respirations in 30 seconds and multiply by 2 to get breaths per minute. If they are irregular, count them for one minute straight.

•“Respirations are normal. The amount of breaths was ___ which falls between the normal range of 10 to 20 breaths per minute for an adult.”

•Watch for signs that an arm cannot be used (IV, surgery, etc.).

•“I am going to take your blood pressure now.”

•Palpate BP, then auscultate. Average BP for an adult: 120/80. High systolic is over 160. Low systolic is 90 or lower. Notify physician if systolic is below 90, because it needs to be at least 90 to perfuse the vital organs. 120-139/80-89 (prehypertensive), 140-159/90-99 (stage I hypertensive), >160/>100 (stage II hypertensive).

•“Blood pressure is 120/80, which is the normal blood pressure value for an adult.”

•“I am going to place this pulse oximeter on your index finger. It won’t hurt and it will be quick!”

•Use pulse oximeter on patient’s index/pointer finger. Normal range is 97%-100%. Must maintain at least 92%. For an oxygen saturation below 92%, it is necessary to put the patient on oxygen.

•“Oxygen saturation is 97% which falls under the normal range of 97-100%.”

•“On a scale of one to ten, one being no pain and ten being the worst pain you’ve experienced, rate your pain at this moment.”

•Ask when last pain medication was given. Describe follow-up for:

1) IV pain medication administration- note response in 15 minutes.

2) Oral pain medication administration- note response in 40 minutes to one hour

•Ask: “Is your pain better?”

1. Describe the Glasgow Coma Scale components and possible findings in each category

2. Assess pupillary light reflex and describe normal findings

3. Assess upper muscle strength and describe normal findings

4. Assess lower muscle strength and describe normal findings

5. Assess facial symmetry: describe normal findings

6. Assess Communication: describe normal findings

7. Assess ability to swallow: describe normal findings

a. Assess best eye response: “The patient’s eyes opened spontaneously (4) when I walked in the room.”

•Spontaneous (4), Speech (3), Pain (2), No Response (1)

b. Assess best motor response: “Can you wiggle your fingers for me? The patient responded to my command(6).”

•Obeys commands (6), localize pain (5),flexion withdraw (4), decorticate (3), decerebrate (2), no response (1)

c. Assess best verbal response: “Can you tell me what your name is, where you are right now, and what day, month, and year it is?”

•Oriented x 3-person, place, time(5), Conversation Confused (4), Speech Inappropriate (3), Speech Incomprehensible (2), no response (1)

“I am going to shine a light in both of your eyes in just a moment. Can you please look at an object in the distance while I do this?”

•“The pupils are equal, round, and reactive to light. They are 3 mm, which falls in the normal pupil size range of 3 to 5 mm. In response to the light, they constrict briskly by 1 mm.”

•PERRL- Pupils Equal Round Reactive to Light

•Note Size(3-5mm), Shape(round), symmetry(equal)

1. Describe normal respiratory rate and respiratory effort

2. Auscultate breath sounds over the anterior lobes only

a. Describe your findings on sim-man

b. Describe the normal breath sounds, describe where they are most likely heart over the chest landmarks.

“I am going to listen to your lung sounds. Take a few deep breaths for me please.”

•Listen to 5 landmarks per side comparing side to side along the way

•Normal- Wooshing Air

•Crackles-popping noise during inspiration (fine- rubbing hair together/coarse- separating velcro)

•Wheezing- musical snore or moan on expiration (high- many notes/ low- 1 note)

•Stridor-Inspiratory Crowing Sound

“I heard bronchial breath sounds over the patient’s trachea and larynx, Bronchovesicular breath sounds around the upper sternum, and vesicular sounds over the peripheral lung fields when I auscultated the lung sounds.”

•Bronchial Sounds- By trachea/larynx (apex of lungs)

•Bronchiovesicular- between scapulae

•Vesicular- Over most of lung field

1. Auscultate rhythm at apex and describe normal findings

2. Assess apical versus radial pulse and describe normal findings

3. Demonstrate palpation of the temporal, carotid, brachial, and radial pulses

4. Assess heart sounds in all auscultatory areas.

   a) Demonstrate correct placement of stethoscope.

   b) State each area where you place the stethoscope

   c) describe normal findings in each area

5. Demonstrate assessment of capillary refill (fingers and toes) and describe normal findings

6. Demonstrate assessment for pretibial edema and describe normal findings

7. Demonstrate palpation of posterior tibial pulses and palpate the dorsalis pedis pulses. State the rate and grade.

“The apical pulse and radial pulse occur simultaneously.”

•If not equal, record pulse deficit- may be indication of heart failure

4. Assess heart sounds in all auscultatory areas.

a) Demonstrate correct placement of stethoscope.

b) State each area where you place the stethoscope

c) describe normal findings in each area

“I always listen to the heart in a number of places on the chest. Just because I am listening a long time, it does not necessarily mean that something is wrong.”

•Auscultate first with diaphragm then with bell

•1- note rate and rhythm, 2- identify S1 and S2, 3- assess S1 and S2 separately, 4- listen for extra heart sounds 5-listen for murmurs

•Valve areas:
   -Second right interspace—aortic valve area

   -Second left interspace—pulmonic valve area

   -Left lower sternal border—tricuspid valve area

   -Fifth interspace at around left midclavicular line—mitral valve area

•Normal: S1 and S2 regular, S2 loudest at base, S1 loudest at apex, No extra heart sounds (S3, S4), No murmurs

**I am going to check the capillary refill first in your fingers and then your toes**

“Color returns promptly, in less than 1-2 seconds, in both fingernails and toenails.”

“There is no edema present (there is no indentation when I press on the skin, and there is no swelling of the leg).”

1. Color: describe normal, and state 4 abnormal skin assessment findings that indicate pathology

2. Temperature: demonstrate assessment and describe normal findings on arms and legs

3. Pinch a fold of skin under clavicle or on forearm. a) State what this assessment is called. b) State what is normal. c) State what is abnormal.

4. Note any lesions; check for dressings.

5. Note skin around IV site

6. State the name of the standardized scale that is used to quantify risk of skin breakdown

7. Describe the 4 stages of pressure ulcer development

“The skin is Even in tone, and consistent with racial heritage. It feels smooth, and firm with even surface. No lesions. Skin is a pinkish tan color.”

•Abnormalities- Pallor (white- vasoconstriction), cyanosis (bluish- due to lack or perfusion) , jaundice(yellowing- bilirubin in liver), erythema (redness- from excess blood flow), lesions

“Temperature is warm and dry bilaterally.”

•use back of hand to feel arms and legs

3. Pinch a fold of skin on forearm.

a) State what this assessment is called.

b) State what is normal.

c) State what is abnormal.

“I am just going to pinch some skin on your forearm. This won’t hurt. 'Mobility and turgor (a)' are normal. The skin rises with ease and promptly returns upon release after I pinch it, indicating adequate hydration (b).”

c) Mobility (rising) is decreased with edema; turgor (prompt return) is evident in severe dehydration or weight loss. The pinched skin recedes slowly or “tents” and stands by itself

•Stage I- intact skin red but unbroken

•Stage II- Partial-thickness skin erosion with loss or epidermis and some of dermis. Looks like open blister

•Stage III- Full-thickness extending to subcutaneous tissue; looks like crater. May see some fat

•Stage IV- Full- thickness involving all skin layers and goes into supporting tissue. Muscle, tendons, and bones may be exposed, and slough (stringy) or eschar (dead tissue) present

1. Assess contour of abdomen and describe normal findings

2. Assess bowel sounds in all four quadrants and describe normal findings

“The contour of the abdomen is flat.”

•Should be flat or rounded and bilaterally symmetrical

•Scaphoid (curved inward), protuberant (distended)

“I am now going to listen to your bowel sounds. I’m just going to lift up your gown for a bit. I hear normal bowel sounds in all four quadrants.”

•Normal- high-pitched, gurgling, cascading sounds, occurring irregularly anywhere from 5 to 30 times per minute.

1. Inquire if voiding regularly

2. Assess and describe normal urine for a) color, b) clarity and c) quantity

3. Demonstrate a) palpation of the suprapubic area of abdomen to determine if bladder distended, b) describe follow-up for abnormal findings

“Are you having trouble going to the bathroom? About how many times do you go per day?”

•Normal is 5-6x per day; 4-6 hours after surgery

a) colorless to light yellow

b) clear

c) 5-6 times per day, 800 to 2000 mL per day with a normal fluid intake of about two liters per day.

•Polyuria (excessive), Oliguria (diminished)

1. Assess the following if on bed rest: a) check if head of bed is elevated, if not elevate to desired height in degrees, b) Describe 3 causes of skin breakdown

2. Assess if SCD’s are on and connected to foot pumps. State the minimum number of hours SCD’s must be on to be effective.

3. Assess if assistance needed, how movement is tolerated, ability to turn, ability and distance walked to chair.

4. Assess need for any ambulatory aid or equipment

5. State common scale used to quantify risk for falling

1. Assess the following if on bed rest:

a) check if head of bed is elevated, if not elevate to desired height in degrees

b) Describe 3 causes of skin breakdown

a) Elevate to 15 degrees; Aspiration Precaution 45 Degrees

b) 3 causes of skin breakdown

1-friction, 2-shearing, 3-sustained pressure, Impaired Mobility, Thin/Fragile Skin, decreased sensory perception, impaired level of consciousness, moisture (urine/stool), excessive perspiration/would drainage, poor nutrition, infection

Must be on 22 out of 24 hours in order to be effective

(Sequential Compression Device—external support used to help reduce edema in lower extremities)

1-Return bed to lowest height

2-Verify that brakes are locked

3-Make sure appropriate rails are up

4-Ensure call bell is available

5-Verify bed alarm, if indicated

6-Initiate or continue appropriate plan of care

7-Complete assessment and document into computer “It looks like everything is normal, so I’m going to continue with the appropriate plan of care. I’m going now, but I will be back later to check on you. If you need me for any reason, the call bell is right here. Just press it and I will come as soon as I can.”