Notes
- Assess level of orientation, level of consciousness (LOC), and responsiveness (LOR).
- Assess airway, breathing, and circulatory status (ABCs).
- Obtain STAT bedside finger stick blood glucose (FSBG) level for decreased LOR.
- Inspect skin for temperature, moistness, color, and central or peripheral cyanosis.
- Inspect Pt for use of accessory respiratory muscles.
- Palpate peripheral pulses for rate, rhythm, character, or diminished pulses.
- Auscultate lungs for wheezing, rhonchi, crackles, and rales.
- Assess ECG (if monitored), and treat arrhythmias per order as indicated.
- Assess baseline VS (HR, RR, BP, SpO2, temp), and obtain a SAMPLE history.
- Assess level of pain, distress, or symptom characteristic (See OPQRST).