203 COMPLETE SYSTEMS ASSESSMENTS
FALL 2023
SASKATCHEWAN POLYTECHNIC & UNIVERSITY OF REGINA
SCBSCN
,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
FALL 2023
SASKATCHEWAN POLYTECHNIC & UNIVERSITY OF REGINA
SCBSCN
,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
