Initial cardiac shift assessment (Genito/ Urinary (Last Pu, time Dipstick,…
Initial cardiac shift assessment
Safety checks completed: O2 airway, GTN spray/ suction/ electrical/ alarms/ pt id/ check patients
Check patients medications, dosages, times due,
Motor strenth, Pupils, reaction
temperature, how this was taken.
Chest expansion - symmetrical/ asymmetrical: respiratory patten, no distress or laboured
Breath sounds - posterier and anterior
Rhythm and rate, Stable/ unstable : Caprillary refill more than 3 seconds or less
Peripherial pulses - Absent/ Present
Oedema - site?
Beta blockers Y/N
CVL/ IV site
Date inserted/ status/ Site care
Are they on a fluid balance or restriction, weight, Bowel movement, and treatment
Last Pu, time Dipstick, Colour
IDC, size, no of days and is it secure
Skin, warm/cool/ clammy/diaphoretic. Colour: Normal/palee/cyanotic/Jaundiced/Mottled. Skin breakdown: signt location
Nil/ constant/ on activity, sharp/ dull/ burning: Does it radiate?
Medication taken to help with pain
Patient subjective pain scale. 0-10