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Summary Detailed Assessment Notes for CNUR 203 OSCE (Fall 2023) CA$13.43   Add to cart
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Summary Detailed Assessment Notes for CNUR 203 OSCE (Fall 2023)
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I created these notes based on the "CNUR 203/204 Systems Assessment Worksheet for 2022/2023." I omitted the CNUR 204 information to keep the notes more concise and relevant. The provided "Systems Assessment Checklist" only includes main points for each assessment, but does provide details about lan...

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  • April 1, 2024
  • 25
  • 2023/2024
  • Summary

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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

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