1. Prepares for patient contact ppe/handwashing
2. Introduces him/herself to the patient.
3 identifies his/herself to bedside nurse/doctor
1. Obtain information regarding patients history/ entrance complaint
2. Observe the patients vital signs displayed on the monitor.
3. check position of the patient
4. Chest auscultation
5. Checking urine output
1. Prioritizing actions.
2. ABC & LOC Assess patient airway, breathing and circulation, and level of consciousness .
3. Focus assessment of systems based on patient's presentation, s/s.
Identify actual and /or possible medical problems or nursing problems that presenting with all assessment performed
Discuss finding with lead nurse/charge nurse or /and instructor .
Initiate the priority interventions , transcribe and incorporate providers orders , question orders that are not clear.
Delegate tasks to supportive personnel.
Communicate with the provider in the timely manner.