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