ASSESSMENT PHASE

Look Test History/Background Data Head to Toe/Physical Assessment

1. Look Test/Initial ABC Check

(client may be sleeping, not necessary to wake)

-observe client for breathing

-observe the client's position and comfort

2. Collect History/Background Data

-kardex, chart, medication record, shift report
-dx, medical history, admission story, laboratory
values(if prioritized for client)
-current medical plan of care
-shift report data

Proceed to Head to Toe Assessment (physical examination)

 Head to Toe Assessment (physical examination)

1. ABC Chunk
-safety equipment check: oxygen equipment, suction
-Alertness, rousability (LOC)
-SOB, Dizziness, CP, any other pain
-Vitals
-lung sounds, apical heart sound, bowel sounds,
-urine output (quantity sufficient, color)

2. Upper Body
-skin integrity,/CWMS/edema of arms & chest
-abdominal distention, abdo palpation
-site to source of any tubes/drains/ivs

3. Lower Body
-skin integrity/CWMS/edema assessment of legs, -
-palpate pedal pulses
-site to source of any tubes/drains/ivs

4. Other Subjective Data Questions

-orientation, LBM, N/V/D, sleep,
- -any other voiced concerns

Laboratory Values
-CBC, lytes, Creat, other blood work
-microbiology; C& S

Other Tests/Procedures
alues
 Time Sequencing Plan of the Applied Nursing Process (TSPANP)

0630-0640
-preconference

0640-0700
-confirm patient assignment
-introduce to Nurse: state: name, title, specific responsibility/goals for shift & scope of
practice
-Look test/ABC check

0700-0720
-collect client history/background data from charts: kx, chart, MAR, shift report

720-0745
-complete head to toe assessment
-document vitals

0745-0800
-prioritize variances/abnormalities from assessment data
-develop plan of care

0800-0810
-collaborate priorities and plan of care with your nurse
-adjust/enhance plan of care in collaboration with nurse

0810-0845
-implement plan of care within your current scope of practice
-(ie. medication admin, reassessments, collaborate with medicine)
-set up/assist (basic hygiene-face, mouth) for breakfast

0845-0930
-develop & implement a specific plan for complete morning care/wash
-complete additional/remainder client assessments and/or reassessments (ie. Complete
Skin integrity assessment during morning wash)

0930-1000
-collect current laboratory values (priotize, develop plan of care, collaborate as per the lab
values data)
-document: (ie. Vitals, diabetic, pain flow sheets, nurses notes)
1000-1030
-report off to Nurse
-break

1030-1200
-Look Test (include pain assessment)
-continue/complete:
morning care, reassessments, documentation
-mobilize client

1200-1300/1330
-med admin
-reassessments
-recollaborate & report off with nurse

13/1330-14
-post conference
Name: Age: Dx: Hx:
Room:
Code Status:

MD/Service:

ABC: SOB___ DIZZINESS_____CP_________PAIN:________

NEURO GU
A&O *3___ LOC:____ Foley___BR:____
Conv approp___ QS____
Coop& plesnt___
Sleep___
GI
CVS Diet order_______type_______
Apex_______Rad______ Glucs: 08______12_____18___
Reg___Irreg___ Abdo soft___nodist___
BS*4____N/__ V/__ D/___PG__
BP________HR_____ LBM:
Edema:
PPP____CWMS___ SKIN/ IVS/ DRAINS
Temp_____
FVB_______

RESPS
Chest:
SOB______Cough: Procedures/Tests
Reg_____easy_____rate___
SpO2_________on________

MOBILITY
Activity order:
Assistance level:

LABS DC PLAN Target date:

INR_______ Home or Facility:
WBC______ Hb________
Creat______ K_________ Issues/Concerns:
Questions/notes

Current Medical Plan of Care

Client Plan of Care

i. R/a…@ time
ii Collab..@time
iii. Hold/Provide(Medical Interventions)