1. CNA2 OSBN Curriculum

2.  Temp > 38 degrees C or 100.4 F  SBP > 170 or < 90 ◦ Retake manually if done with machine  DBP > 90 or < 50 ◦ Retake manually is done with machine  Respirations > 24 or < 12  HR >110 or < 50 http://www.medcomrn.com/dev/flash/ flvplayer/movie.php?movie=http://ss1. medcomrn.com/flv/cna515r_sec02_30 0k.flv&title=&detectflash=false

3.  Intake ◦ Decreased due to N/V  Output ◦ UOP  <30 ml/hr or 240ml/8hr  Appearance of Blood ◦ Emesis ◦ Sputum ◦ Urine ◦ Stool

4.  ADL’s  Movement

5.  Blood Glucose ◦ If 400 ◦ NOTIFY NURSE IMMEDIATELY!!!

6.  SOB  Dyspnea  Cough  Sputum ◦ Note Color ◦ Note Changes

7.  N/V  Poor Appetite  Difficulty Swallowing/Eating  Urine ◦ Sediment ◦ Foul Odor ◦ Pink Colored ◦ Dark Tea Colored  Stool ◦ Melena ◦ Frank Blood

8.  Excessive Drowsiness  LOC  New Onset ◦ Confusion ◦ Weakness ◦ Agitation  New ◦ Inability to Communicate ◦ Drooling while Awake ◦ Facial Droop

9.  Location  Intensity  Onset  Duration  Chest Pain  Sudden Change in Pain Level

10.  Cyanosis  Pallor  Chills  Diaphoresis  Edema  Any Drainage  Rashes/Bumps/Sores

11.  Dislodgment of any Tubes/Drains  Physical Signs of Abuse  Verbalization of Abuse  Pt. Expressing Concerns ◦ Code Status