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Health Assessment

Health Assessment. Min Choi, RN, MSN, CCRN. Neuro system. GCS, A&O Pupil sizes/reaction ROM/MAE, ambulation Pain issue-PRN, PCA, location If stroke pt, any residual. Cardiovascular System. Heart rate/rhythm, BP, BP meds Pulses Edema CVP, PAWP, Swan ganz cath (size, length).

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Health Assessment

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  1. Health Assessment Min Choi, RN, MSN, CCRN

  2. Neuro system • GCS, A&O • Pupil sizes/reaction • ROM/MAE, ambulation • Pain issue-PRN, PCA, location • If stroke pt, any residual

  3. Cardiovascular System • Heart rate/rhythm, BP, BP meds • Pulses • Edema • CVP, PAWP, Swan ganz cath (size, length)

  4. Respiratory Stystem • Oxygen (NC, Mask, etc), satting • Trach (size, cuff/uncuff) • ETT (size, location at lip/teeth) • Ventilation (setting) • Lung sounds • Cough, sputum characteristics • Chest tube? • Drainage, air leak? • Where • What kind

  5. GI System • Diet type • NGT/dobhoff/GT • TF formula, rate (goal), residual • ABD soft/distended/BS • Last BM, charateristics • Rectal tube/bag • TPN/Lipid • Accucheck/sliding scale • Colostomy/ileostomy • Stoma assess if present

  6. GU System • Foley/void • Urine charateristics • Anuric/HD • Dialysis access • Any diuretics • Any irrigation • Ampho B/plain NS • Suprapubic cath?

  7. Skin • Skin tear? • Any eccymosis? • Dermal ulcer?- if any, stage, characteristics, treatments • Surgical incision

  8. IV Access • Peripheral IV (where, what size) • Any solution? • Central line- TL, DL, SL, PICC • Dialysis cath/access • Arterial line

  9. Drain/tube • JP • T tube • Any drainage tube/bag • What kind/where/characteristics/amount of drainage

  10. Lab value • Any abnormal lab values • Replacement given • Blood product given • Series of lab, due time

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