Originality from UOIT comments Level of consciousness, position, skin colour, facial expression, presence of distress or pain Subjective

inquiry P Q R S T U Obtain temp* Radial Pulse* will be on monitor Respirations* BP (both arms if cardiac pt)* 02 saturation* Assess orientation Check pupils PERRLA Facial expression/demeanor Inspect anterior chest Symmetry, skin colour & condition, edema Shape & configuration (ribs sloping downward, symmetrical) Costal angle (normal less than 90 degrees) Quality of respirations Palpate Temperature Masses / tenderness Pulsations / heaves Auscultation respirations (anterior) Follows 5 point sequence comparing left to right, clear, good a/e bilaterally, no adventitious breath sounds Assess chest tube/suction/tracheostomy dressing/ oxygen Auscultate heart sounds Appropriate landmarks(APETM sequence)with diaphragm apical rate* Asses with bell*/ left lateral position* Identifies where lub/dub loudest* Listens through diastole & systole Capillary refill (< 3 sec) Palpate peripheral pulses Skin temp edema Muscle strength arms & legs

Inquires about changes in appetite and last BM Inspect Abdomen (contour, symmetry, scars, straie) Auscultate Bowel sounds starting in RLQ and proceeds to RUQ, LUQ, LLQ Must listen for 5 second per quadrant Acknowledge it can take up to 5 minutes to determine absence of bowel sounds Palpation Light palpation (1 cm using fingertips) Deep palpation (5-8 cm using one or two hands)* Assess urine output/size of foley* Assess dressings*/colostomy*/ileostomy*/ileoconduit*/bruits* Assist patient to sit at side of bed (or in high fowlers) Assessment of posterior/lateral chest Inspect Symmetry of chest, skin colour & condition Alignment of spinous process Palpate Tenderness*, masses* Auscultation (posterior and lateral): General auscultation (follow 8 point sequence and 2-3 point for lateral, clear, good a/e bilaterally, no adventitious breath sounds) Environmental Scan Garbage removed Call bell/bed in lowest position Discuss normal & abnormal findings and plan for medication with facilitator Discuss priorities of care using diagnosis, assessment findings, lab values Determine appropriate medication to prepare Assess patient: Any required assessments IV site for phlebitis/infiltration Bag, tubing, solution, TBA, rate etc Critical thinking Mechanism of action Onset/peak/duration

Side effects/adverse reactions Compatibility/Run time (IV monograph) Dose Calculation (pump & gravity rate) Right Patient Right Medication Right Dose Right Route Right Time Right Frequency Right Reason Right Site Allergy check Check MAR verification Right Patient Right Medication Right Dose Right Route Right Time Right Frequency Right Reason Right Site Prepares accurate drug label Right Patient Right Medication Right Dose Right Route Right Time Right Frequency Right Reason Right Site Rechecks dose calculation (pump & gravity) Copy unique # Check unique # to patients wristband & rechecks allergy Attach piggyback using sterile technique Regulates rate accurately Documentation: Date/time/dose/signature Signature Profile Comments