Summary CNUR 107 Detailed System Assessments with Step-by-Step Guidance (for OSCE or Final Exam)

107 SYSTEM ASSESSMENTS
SASKATCHEWAN POLYTECHNIC, UNIVERSITY OF REGINA

SCBSCN

WINTER 2023

YEAR 1

,60 SECOND
ABCS

AIRWAY

A & O x 3?

Check name band & confirm DOB

 Airway open?
 Able to talk
 Speak clearly

BREATHING

Must state 2

 How are they breathing? (relaxed, effortless, even?)
 Rate (fast/slow) normal 10-20/min
 Struggling?
 Accessory muscles?

CIRCULATION

 Colour of skin (consistent/even)
o Must assess whole body to state consistency throughout
 Abnormal colour?
 Capillary refill (should be > 2 secs)
 Mentation – alert/confused/hallucinating

At this point…

1. Any further assessing
2. Anything wrong with ABC
3. Anyone need to be called? Urgent/non-urgent

TUBES/LINES/DRESSINGS

 IV – follow tubing to pump & bag & ensure correct rate/solution
 Saline lock - check site
 NG tube
 Suction - is it working? Is it being used
 Drains – type, describe drainage, suction
 Catheters – bag location? Tubing? Urine colour/amount

,  Chest tubes – suction? Colour of drainage? amount
 Cardiac monitor telemetry

RESPIRATORY EQUIPMENT

 Oxygen delivery device
 Is O2 device hooked up to wall?
 Is O2 running at correct rate?
 Is suction working properly?

PATIENT SAFETY SURVEY
 Bed rails up (as requested)  A&O
 Call bell within reach  Fall risk?
 Bed in lowest position  Must state at least one…
 Brakes on o Glasses
 TLR logo o Hearing aids
 Allergy bracelet (if applicable) o Mobility aids


ENVIRONMENTAL SURVEY
 Floor  Clear path to bathroom/door
 Clutter

SENSORY
 Hear  Smell
 See  Feel


CHECK YOURSELF

Additional helpful info & Unanswered questions

 Vital signs  Lab work
 Meds  BGM results

, GENERAL SURVEY & Visualize

patient
ENTIBE




Must state name of section & 2 descriptors under each

PHYSICAL APPEARANCE
 Healthy  Facial features
 Well-groomed  Appears stated age
 Alert  Acute distress?
 Skin colour

BODY STRUCTURE

1. Nutritional status – obese/average/skinny
2. Posture – comfortable
3. Position – comfortable
>indicatete
4. Body build – equal bilaterally? Deformities?

MOBILITY

 Gait – smooth/even/balanced
 Limitations – move all limbs? Involuntary movements? Any reason to NOT get them out of bed?

BEHAVIOUR

 Facial expressions – eye contact? Appropriate expression?
 Speech – clear & understandable
 Mood & affect – cooperative? Comfortable? Congruent?