60 second assessment

60 SECOND ASSESSMENT
 ABC’s
- AIRWAY (assess airway – provide evidence that airway is clear)
o Is the patient speaking clearly?
o Are they eating?
o Are they drinking?
- BREATHING (assess that breathing is adequate and that there’s no difficulty breathing)
o What is their respiration rate?
 normal is 10-20 breaths per minute.
o What is the quality of their respirations?
 they should be regular and relaxed.
o Are there any signs of distress?
o Is there accessory muscle use?
- CIRCULATION (assess client’s colour and mentation)
o Is there any visible signs of cyanosis or pallor?
o Is the client’s skin colour consistent throughout?
o Is the pt’s skin return to normal colour in less than 2 sec with cap refill?
o Check their LOC & Orientation
 Are they alert, lethargic, drowsy, or unresponsive?
 Are they orientated to person, place, time and/or situation?

 TUBES, LINES, AND DRESSING
- Are there any tubes or is there any IV running?
o if there is an IV,
 is it the correct IV solution?
 Is it at the correct rate?
 Is it connected properly?
 Assess the IV insertion site for patency, swelling, redness, discharge, or
leakage.
o If there are tubes
 For a foley catheter (note the amount, colour, clarity, and odor of urine)
 For any other tubes (assess patency, colour & amount of drainage)
o Is there any dressing?
 If so
 Inspect site (note location, any redness, swelling)
 Is it D&I (dry and intact)?
 If drainage is present, describe amount and colour.