bedside evaluation checklist
Patient Identification and Consent
General Observations
Vital Signs
- Use a blood pressure cuff and a sphygmomanometer to measure the patient's blood pressure
- Place the cuff around the patient's upper arm, ensuring it is snug but not too tight
- Position the patient's arm so that it is at the same level as their heart
- Inflate the cuff until the pressure exceeds the patient's systolic blood pressure
- Slowly release the pressure in the cuff while listening for the Korotkoff sounds
- Note the pressure at which the first Korotkoff sound is heard (systolic pressure) and when the sound disappears (diastolic pressure)
- Record the patient's blood pressure in millimeters of mercury (mmHg)
- Palpate the patient's pulse by gently placing your fingers on a peripheral artery (e.g., radial artery)
- Count the number of beats you feel within a 60-second period
- Assess the regularity and strength of the patient's pulse
- Note any abnormalities in heart rate or rhythm
- Record the patient's heart rate in beats per minute (bpm)
- Observe the patient's chest rise and fall during breathing
- Count the number of complete breaths the patient takes within a 60-second period
- Assess the depth and rhythm of the patient's breathing
- Note any signs of respiratory distress or abnormal breathing patterns
- Record the patient's respiratory rate in breaths per minute (bpm)
- Choose an appropriate method to measure the patient's body temperature (e.g., oral, tympanic, axillary, rectal)
- Follow the manufacturer's instructions for using the thermometer
- Clean the thermometer probe before and after each use
- Place the thermometer in the appropriate location and wait for the reading to stabilize
- Record the patient's body temperature in degrees Fahrenheit (F) or Celsius (C)
Integumentary System
Respiratory System
Cardiovascular System
Gastrointestinal System
Genitourinary System
Musculoskeletal System
Neurological System
Psychosocial Assessment
- Observe the patient's facial expressions, body language, and tone of voice for any signs of distress or sadness
- Ask open-ended questions to explore the patient's emotional state and any potential stressors they may be experiencing
- Use validated assessment tools such as the Patient Health Questionnaire (PHQ-9) or Generalized Anxiety Disorder (GAD-7) scale to quantify the patient's emotional well-being and mood
- Ask the patient about their relationships with family, friends, and significant others to assess the availability of emotional support
- Discuss the patient's living situation and any potential challenges or isolation they may be facing
- Inquire about the patient's involvement in community activities or support groups to gauge their level of social interaction
- Use clear and simple language to explain the patient's diagnosis, prognosis, and recommended treatment options
- Assess the patient's knowledge about their condition by asking them to explain it in their own words
- Address any misconceptions or gaps in understanding by providing additional information or resources as needed
Use in Manifestly