Directions: Enter the patient’s room. Observe the patient, family, and environment for up to 60 seconds, while reviewing the following questions in your mind:
Assess Airway Breathing Circulation (ABCs) without touching the patient * What data lead you to believe there is a problem with airway, breathing or circulation? * Is the problem urgent or nonurgent? * What clinical data would indicate that the situation needs immediate action and why? * Who needs to be contacted and do you have any suggestions or recommendations?
Assess Tubes and Lines * Does the patient have any tubes or an IV? * Is the IV solution the correct one at the correct rate? * Does the patient need those tubes? If so, why? * Do you note any complications? * What further assessments need to be done?
Assess Respiratory Equipment * If the patient is using an oxygen delivery device, what do you need to continue to monitor to ensure safe and effective use of the system?
Patient Safety Survey * What are your safety concerns with this patient? * Do you need to report this problem and to whom?
Environmental Survey * What in the environment could lead to a problem for the patient? * How would you manage the problem?
Sensory Assessment * 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”?
Additional Assessment * What additional information would be helpful for further clarification of the situation? * What questions are unanswered? What answers are unquestioned?
After your assessment: Meet with your fellow students and faculty. Review each student’s patient. Decide which patient you would focus on first as a team, and why. Determine which elements of the team’s work require continual situation