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60 second assessment - CNUR 101, 107, 203, 204
- Course
- CNUR 107
- Institution
- University Of Regina ( )
physical assessment
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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.
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