Patient Assessment
4 critical life functions - ANS 1. Ventilation
2. Oxygenation
3. Circulation
4. Perfusion
Measuring Ventilation - ANS RR, Vt, chest movement, breath sounds, PaCO2, end-tidal CO2
Measuring oxygenation - ANS Heart Rate, color, sensorium, PaO2 and SpO2
Measuring circulation - ANS Heart rate, strength, and cardiac output
Measuring perfusion - ANS blood pressure, sensorium, temperature, urine output, and
hemodynamics
First priority is emergency - ANS Ventilation
Admission Chart Notes - ANS Admitting diagnosis
History of present illness
Chief complaint
Past medical history
Current medications
Signs and symptoms - ANS Signs: objective info, things that you can see or measure
Symptoms: subjective info, things the pt tells you
Advanced directives - ANS a written statement of a person's wishes regarding medical treatment,
often including a living will, made to ensure those wishes are carried out should the person be
unable to communicate them to a doctor
,Respiratory care orders - ANS 1. Type of treatment
2. Frequency
3. Medication dosage and route of administration
4. Physician signature
Patient progress notes - ANS respiratory notes
nursing notes
admission notes
physician notes
maternal history and neonatal data
Patient laboratory reports - ANS ABG analysis
pulmonary function testing
imagining reports ( x-rays, CT, MRI, PET, ect.
basic lab assessments (CBC etc.)
Intake and output - ANS Normal urine Output: 40 mL/hr (~ 1 Liter/day)
Sensible water loss :
urine, vomiting, diarrhea
Insensible water loss :
lungs, skin
Fluid balance - ANS Changes in the CVP indicate changes in fluid balance
Decreased CVP: indicates hypovolemia; give fluids
Increased CVP: indicates hypervolemia; give diuretics
medication reconciliation - ANS Process of ensuring pts medications list is as accurate and up to date
as possible
Must be carried out within 24 hrs of admission
, Alert and responsive - ANS level of consciousness: normal
Lethargic, somnolent, sleepy - ANS consider sleep apnea or excessive O2 therapy in patient with
COPD
Stuporous, confused - ANS responds inappropriately, drug overdose, intoxication
Semicomatose - ANS responds only to painful stimuli
Obtunded - ANS Drowsy state, decreased cough and gag reflex, aspiration risk
Coma - ANS Does not respond to painful stimuli
Activities of daily living (ADLs) - ANS Basic self-care tasks such as
eating
bathing
toileting
walking
dressing
Orthopnea - ANS Difficulty breathing when lying down
Consistent with CHF
General Malaise - ANS Run down feeling, Nausea, Weakness, Fatigue, Headache
Caused by electrolyte imbalance
Edema - ANS Excessive fluid in the tissue
Occurs in arms, legs and ankles
Caused by CHF or renal failture
4 critical life functions - ANS 1. Ventilation
2. Oxygenation
3. Circulation
4. Perfusion
Measuring Ventilation - ANS RR, Vt, chest movement, breath sounds, PaCO2, end-tidal CO2
Measuring oxygenation - ANS Heart Rate, color, sensorium, PaO2 and SpO2
Measuring circulation - ANS Heart rate, strength, and cardiac output
Measuring perfusion - ANS blood pressure, sensorium, temperature, urine output, and
hemodynamics
First priority is emergency - ANS Ventilation
Admission Chart Notes - ANS Admitting diagnosis
History of present illness
Chief complaint
Past medical history
Current medications
Signs and symptoms - ANS Signs: objective info, things that you can see or measure
Symptoms: subjective info, things the pt tells you
Advanced directives - ANS a written statement of a person's wishes regarding medical treatment,
often including a living will, made to ensure those wishes are carried out should the person be
unable to communicate them to a doctor
,Respiratory care orders - ANS 1. Type of treatment
2. Frequency
3. Medication dosage and route of administration
4. Physician signature
Patient progress notes - ANS respiratory notes
nursing notes
admission notes
physician notes
maternal history and neonatal data
Patient laboratory reports - ANS ABG analysis
pulmonary function testing
imagining reports ( x-rays, CT, MRI, PET, ect.
basic lab assessments (CBC etc.)
Intake and output - ANS Normal urine Output: 40 mL/hr (~ 1 Liter/day)
Sensible water loss :
urine, vomiting, diarrhea
Insensible water loss :
lungs, skin
Fluid balance - ANS Changes in the CVP indicate changes in fluid balance
Decreased CVP: indicates hypovolemia; give fluids
Increased CVP: indicates hypervolemia; give diuretics
medication reconciliation - ANS Process of ensuring pts medications list is as accurate and up to date
as possible
Must be carried out within 24 hrs of admission
, Alert and responsive - ANS level of consciousness: normal
Lethargic, somnolent, sleepy - ANS consider sleep apnea or excessive O2 therapy in patient with
COPD
Stuporous, confused - ANS responds inappropriately, drug overdose, intoxication
Semicomatose - ANS responds only to painful stimuli
Obtunded - ANS Drowsy state, decreased cough and gag reflex, aspiration risk
Coma - ANS Does not respond to painful stimuli
Activities of daily living (ADLs) - ANS Basic self-care tasks such as
eating
bathing
toileting
walking
dressing
Orthopnea - ANS Difficulty breathing when lying down
Consistent with CHF
General Malaise - ANS Run down feeling, Nausea, Weakness, Fatigue, Headache
Caused by electrolyte imbalance
Edema - ANS Excessive fluid in the tissue
Occurs in arms, legs and ankles
Caused by CHF or renal failture
