Clinical Assessment Tool
Patient
______Patient name outside of room
______Wrist band: Name verified with patient and DOB
______Correct names/dates on whiteboard inside patient room
Tubes and Lines – follow each line from patient to device, look at connections, amount of room to move, secured in place, and labels
Oxygen
______Nares – any skin breakdown
______Source – flow rate______, ordered flow rate______
Feeding tubes (DH)
______Nares – any skin breakdown
______Source– label on bag______, dated______
______Irrigation set-up – clean/dated______
Abdominal tubes
______Type: G-tube (input) Biliary tube (output)
______Site – described in pathway______, labeled______, bag attached______
Chest tube
______Site – described in pathway______, dressing intact______
______Tubing – no kinks______, tight connections______
______Pleurovac – check fluid levels and movement of fluid in
______Suction chamber
______H2O chamber
______Drainage chamber
Drainage
Amount noted on chamber______
Tracheostomy
______Description of trach and size written on pathway
______Suction catheters available in room
______Extra trach tube available in room
______Obturator in sight
______Sterile water at bedside for trach care? Dated if opened______
Foley
______Date of original insertion noted on pathway
______Tubing – dependent and without loops
______Drainage bag – below level of bladder
IV’s
______Site – inspect for redness, swelling, warmth, tenderness, drainage
______Follow tubing to solution – check connections______, label______
______Solution – Correct drug______, time______, dose______, route______
Compare all of above to MAR/admin RX
______Pump: Green light______Plugged in to wall socket______
Environment
______Side rails – necessary?
______Bed in low position
______Call light working and within reach
______No obstacles/clutter at bedside or in route to bathroom
______No obstacles in route to sink
______No obstacles at bedside
______Patient assistive devices within reach – i.e. glasses, hearing aids
______Correct date/nurse name on white board in patient room
______Water pitcher or glass available and clean
______Urinal at bedside
______Bathroom or Bedside commode emptied
______Trash receptacle available and within easy reach
Questions for patient (5 minute sit-down)
What would you like to see happen today?
How would you describe your hospitalization – Is there anything that could be done to make it better?
What should nursing students know about what it’s like being a patient in the hospital?
Assessment Tool completed by______and reviewed by______RN
Dmg2/05/08