1.

Check xr, labs before asmt well, if MAP is below 65, fix the blood
a. Labs - h/h, if dangerous call MD , get orders pressure (drip, fluid bolus)
i. K<,4 Mg.<2 Hgb <7, need to replace d. Flush bag and pressure system correct
ii. What is ekg e. Lines - label each line, know where protonix ivp
b. Xr →if they are intubated, is the etub in place, meds can go into
picc in place at the svc or migrated 9. Drips
i. Swan ganz - if its in the right spot , a. Neo or fentanyl, check your bags,
measure, mark it down check it at b. Labeled properly, right rate
least q 4 hrs c. Heparin - get PTT when is it due, do i need to
ii. Ng tube/ og tubes - in right place, titrate?
measure mark it down, confirm d. Drips: Levophed, epi, dobutamine,
placement vasopressin, dopamine, propofol,
2. Check occiput for breakdown amiodarone, heparin - question if it's ok to
3. Chek neuro pause at all?
a. If intubated and cant respond, check Gag, cough 10. Turn pt for skin breakdown / reposition / skin barrier?
reflex a. OOB, IIS, turn q 2
b. Some are sedated but can follow commands: 11. Ted hose/ SCD
weak in upper ext vs lower, spon vs purpose
c. If alert and oriented, are they lethargic, alert, Hourly expectations
obtunded, deeply sedated ● Uo
d. If pt cant talk: check perrla, pupils, brisk, ● Bp
sluggish, size of pupil, equal insize, cough gag ● Heart rhythm rate
reflex, babinski reflex ● Resp rate
4. Cardiac ● O2 sat
a. Listen to s1/s2 ● Swan ganz etc
b. Connected to monitor ● Pain
c. CVP, stripevery 2 hrs ● Temp
d. AV fistula - bruit thrill? ● LOC
e. Heart murmur?
5. Pulm
a. Ausc
b. Recheck xr - improving? atelectasis or pna. If
worsen - let dr know
c. If on mech vent, check settings f drs order
i. Oral care q 2 hr, lips, elevate HOB
6. GU
a. Postop transplant - foleys, u.o. Every hour
b. Reg pt - every 2 hrs
c. Clear cloudy sediment blood clots
d. If no uo all day, are they HD pt, check BUN creat,
check schedule for dialysis
7. GI
a. Bowel sounds 4 quadrants, is there bowel
sounds and should the be on CLD
b. If not, they might have ileus post op tell MD
c. Tubes - peg tube, are they getting osmolyte,
nephro? Are they at the goal indicated by
nutritionist
8. peripheral/ circulation
a. Lines
b. Tubing ok, not expired
c. CVP and A line - make sure pulses in those
areas,
i. Arterial line - Line in artery - most
accurate BP, never push meds
through it , but can draw blood from
it; MAP 65 is gold std unless
otherwise indicated by dr= perfusing
Neurological:​​ There is a HUGE variety of neurological tests that
can be performed. This is my basic testing that I do on all of my
patients regardless of why they are in the hospital. If any of these
are lacking, more investigation should be done into why the patient
has this deficit.
● Is the patient in any kind of pain? Where and what type?
● Are the patient’s pupils equal, round, and reactive to light?
● Is the patient alert & oriented to person (ask their name),
place (where are you?), time (ask the month and year),
and situation (do you know what brought you to the
hospital?).
● Can they move all extremities well?
● Can they squeeze your hands tightly with both of their
hands?
● What about applying pressure with their feet?
● Is their speech clear?
● Do they have any numbness or tingling?
Respiratory:​​ Respiratory can be either a very simple or a very
complicated body system to discuss. It can be as simple as, “This
patient’s lung sounds are clear and they are on room air. No
respiratory deficits noted.” It can also be as complicated to include
ventilators, chest tubes, and oscillators. For your basic respiratory
assessment, here are the questions you should be asking yourself:
● Assess their lung sounds. Do they sound clear, coarse,
wheezy, rhonchorous (it sounds like there is a LOT of fluid
moving around), or decreased (not much air moving)?
● Is their respiratory rate normal (12-20 breaths/minute)?
Are they having difficulty breathing?
● How much oxygen is the patient requiring?
● Do they have a cough? If so, what are they coughing up?
● Do they have a sore throat?
Cardiovascular:​​ The heart can be a very complicated organ if it
wants to be. There are your four heart valves, four chambers,
septums, and arteries and veins attached to complicate things even
more. The heart is also one of the most fascinating organs because
of the ability it has to pump thousands of gallons of blood through
your body every day. Here are the things to think about in your
basic cardiac assessment:
● Assess the patient’s heart tones. Is there a clear S1/S2
(meaning the “lub dub” sound)?
● Are there any murmurs (not a clear “lub dub” from issues
with heart valves), rubs (sounds like friction of heart
rubbing), or gallops (sounds like a horse galloping)?
● What is the patient’s heart rate and rhythm?
● How is the patient’s blood pressure?
● Are they on any medications to affect their blood
pressure?
● How are their radial and pedal pulses?
● What is their capillary refill time?
● Do they have a temperature?
● Are they flushed?
● Does the patient have any edema?
● Are they wearing sequential compression devices to
prevent deep venous thrombi from forming?
● What IVs does the patient have? What is infusing through
them?
Gastrointestinal:​​ Isn’t the GI system just our favorite? I have
realized that the ICU is full of GI. Don’t sign up for my specialty
unless you are ready for lots of secretions and fluids!
● Assess bowel sounds. Are they present, hyperactive,
hypoactive, or absent?
● What is the patient’s diet order?
● Are they having any nausea or vomiting?
● Do they have an nasogastric (NG) tube or gastrostomy
tube (G-tube)?
● If he has tube feeds infusing, what have the residuals
been? (Residuals are checked by putting a 50 mL syringe
into the NG tube and pulling back whatever contents are in
the stomach.)
● When was their last bowel movement? What did this look
like?
● Do they have a colostomy or ileostomy?
Genitourinary:​​ How much urine output a patient has tells you
about a variety of different things. The causes of low urine output
could be because of acute kidney injury, low blood pressure,
infection, and ureter obstruction among other causes. If a patient’s
urine output has decreased, once again ask yourself, “Why?”Some
basics in your assessment include asking the following:
● Does the patient have a Foley catheter in place?
● If so, what is their urine output? If not, then when did they
last urinate?
● Any pain with urination?
● What does the urine look like?
Integumentary (Skin):​​ During my assessment, I look over the
patient’s skin. Note that the most common places for skin
abnormalities and breakdown are where bony prominences come
into contact with surfaces.
● Are there any rashes, bruises, or other abnormalities?
● How is the temperature of their skin?
● Do they have any drains?
● What is draining and how much?
● Do they have any wounds or pressure sores?
● What dressings are in place for these wounds?
Psychological/Social​​: Depending on the unit you are working on,
the psychological assessment may be very short to very in depth. If
you are taking care of a suicidal or bipolar person then your
assessment will be much lengthier.
● How is the patient coping with their situation?
● Are they calm, aggressive, anxious, combative, frightened,
etc.?
● How is their family coping with this situation?
Look at them, monitor, vent, brief overfiew, iv
Look at labs, progress notes, images

Look at them monitor and alarms set correct, drips - t

Look at ubing expired, how much is left, same drug, same rate,
make sure it doesn't run dry,
Look at ventilator - same ordered settings, turn down sedation to
see where they are at to assess GCS

Head to toe
Brief neuro asmt - shine light, pupil , corneal reflex, cough gag
reflexes; if sedated heavily no rxn, hard assess facial symmetry

Look at ET /NG/ OT tube - what cm, is it secure, what is output of

ET tube (secretions or gastric fluids, color, how much coming out,
see the canister, is suction hooked up, how much is in there)

Any central line, dressing, what is in the line, are they labeled, are
they the correct

Listen to heart, lungs, bowel sounds

Belly - hard soft firm
Incisions - dressings
Drains - color, full, smell?
Foley - patent, skin check, uo, color, any sediment,

Check extremities
Pulses, if cant get a doppler to hear pulse
Cap rf
Warm cold sweaty dry

Turn pt to look at back side - skin check

Check bs, blood draw, labs, make sure everything is patent