Brief Bedside Assessment

Brief Bedside Assessment

Equipment
■ Thermometer.
■ Stethoscope.
■ Sphygmomanometer.
■ Procedure gloves.

Assessment
■ Ask about any health problems, allergies, or medications.
■ Ask your patient how he feels now and during the previous month and year.
■ Ask other questions as you assess each body system.

Key Points
■ Modify the procedure to fit the patient’s health status.
■ Observe the environment and the patient’s general appearance.
■ Measure VS, pain status, and pulse oximetry.
■ Use a systematic (e.g., head-to-toe) approach.
■ Assess the integument throughout the exam.
■ Assess the head and neck.
■ Assess the back with patient sitting.
■ Assess the anterior chest (heart and lungs).
■ Assess the abdomen with patient supine.
■ Assess urinary status.
■ Assess upper extremities, including edema and capillary refill.
■ Assess lower extremities, including edema and capillary refill.
■ Assess for spinal deformities with patient standing.
■ Assess balance, coordination, ROM, and gait.
■ While conducting the assessment and interacting with the patient, determine the patient’s orientation to person, place, and time as well as appropriateness to situation.
■ Check Babinski’s reflex and Homans’ sign.

Documentation
■ Document your findings and report any significant changes or findings to the primary care provider.
■ As a student, report your findings to the instructor and the patient’s assigned RN for validation and action.