Health Assessment

1
Health Assessment

• Min Choi, RN, MSN, CCRN

2
Neuro system

• GCS, AO
• 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