60 Second Check and General Survey document 2017 PDF

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Summary

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Introduction to the 60 Second Situational Assessment (Adapted from UPMC Shadyside School of Nursing document. Permission granted by D. Struh) Purpose – This exercise is designed to assist you in the development of situational awareness. In the patient care area, situational awareness focuses on the art of patient observation. This includes routine use of a general survey (observation) of the patient, family and environment during every incidental encounter and periodically at planned intervals throughout the day. Situational awareness promotes a safer patient care environment and helps the nurse develop care priorities and attention to clinical detail.

60 Second Check When you enter the patient’s room - observe the patient, family and environment for up to 60 seconds, while reviewing the following questions in your mind. The first step of this check is assessing A, B, C’s Airway, Breathing, Circulation The following are examples of how to assess: Airway, Breathing & Circulation Airway

Assesses airway & gives evidence eg. Get your patient to talk to you – ask them if they can tell you their name, where they are at, date/year Ask yourself - can this person speak normally

Breathing

Assess breathing by: a. Looking at how they are breathing – is it effortless, relaxed, regular & even b. Are they breathing fast or slow? Normal rate is 10-20 breaths/min c. Are they in any respiratory distress – are they struggling to breath? Are they using other muscles to help them breath (accessory muscles eg. Intercostal muscles)

Assessment Findings

Circulation

Assess circulation & gives evidence: a. color of skin consistent throughout (even tone) – take a look at their upper body and compare to lower body b. Color: pale, cyanotic, dusky, flushed, jaundice, reddened c. Mentation – state of mind or mental activity. Ask yourself is the patient: - Alert - Confused - Hallucinating - Having some Memory loss (hint: if you asked about their name, place & date in the “airway section”, you can usually tell if they are alert and orientated vs. confused)

At this point, ask yourself: Is there any data that leads me to believe there is a problem with ABC’s? If your answer is “no” then you can continue with the rest of the 60 Second Assessment. If there is a problem, is it? Non-urgent or Urgent? If it is urgent does this patient need immediate action? Does anyone need contacted 2. Tubes/ lines/dressings Any tubes: - IV – if so is the correct IV solution running and at the correct rate - Saline locks – what does the site look like? - Nasogastric tube – is it connected to suction? What is the amount & color of drainage? - Suction – is it connected & working properly & running at correct Dr.’s orders - Catheters – is it below bladder? check for kinks in tubing, what color is urine? - Drains – what drainage is in the drain, check dressings - Chest tubes – is there suction to be on? If so, it is working? What color is the drainage - Cardiac monitor - telemetry Does the patient need these tubes? Do you note any complications? What further assessment needs to be done? 3. Respiratory equipment

Oxygen delivery device: nasal prongs, simple mask, Nonrebreather - Is the device on the patient properly? If oxygen device on, is it hooked up to oxygen on the wall? Is oxygen running at the correct rate? ASK yourself: If the patient is utilizing oxygen, what do I need to continue to monitor? How would you know it is functioning properly? 4. Patient safety survey What are your safety concerns with this patient? Do you need to report this problem, and to whom? Example: Is patient confused or fully alert & oriented? Falls risk? Bed rails up as per request of patient? Call bell within reach? Bed in lowest position? Brakes on? 5. Environmental survey What in the environment could lead to a problem for this patient? Example: Anything on the floor that could cause harm eg. Water/urine Is room cluttered? 6. Sensory What are your senses telling you? Do you hear, smell, see, or feel something that needs to be explored? Does the patient's situation seem "right"? At the end of your check, yourself: What additional information would be helpful? What questions are unanswered? Example: Vital signs – what are normal for this patient? Medications? Lab work – anything abnormal results? Blood sugar results

General Survey

1. physical appearance: healthy well groomed disheveled alert skin color/consistent with ethnicity/race – even tone and skin intact Color: cyanotic, dusky, flushed, grey, jaundice, reddened facial features - symmetrical appears stated age Any acute distress? 2. body structure: nutritional status – obese/average/emaciated posture – standing comfortably & erect position – sitting comfortably in chair, on bed -arms relaxed at sides Body build – normal proportions equal bilateral -any obvious physical deformities or congenital defects 3. mobility: gait – smooth, even, well-balanced – base is as wide as the shoulder width -Arm swing symmetrical any limitations – can they move all limbs involuntary movements 4. behavior: facial expressions – maintains eye contact, appropriate expressions speech – clear & understandable -appropriate conversation Mood & affect – cooperative & comfortable with Examiner -agitated, anxious, drowsy, irritable, Withdrawn, uncooperative Ask yourself if Mood and affect congruent or incongruent? Dress/hygiene – appropriate clothing -clean, well groomed...