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