Emergency: What is the person’s code status? Full code? Part code and conditions? No code? When is the last time they had an emergency need? Gait: Does the person require any assistive devices for ambulation? What risk does the person have for falling? Allergies: Does the person have any allergies to medications or anything in the environment? Air: Does the person require any assistive devices for breathing? Is the person able to breathe on his/her own? Are there any potential or real air toxins or pollutants that could affect the person? What is the appearance of the person’s skin or oxygenation level? Food: Does the person require a special diet related to allergies, diabetes (sugar), hypertension (salt), heart disease (fat/cholesterol), edentulous (soft foods), dysphagia (pureed foods), NPO (nothing by mouth), small amounts (gastric procedure), parenteral feedings (unable to eat on own)? Does the person appear hungry? Weight? Water: What is the recommended amount of water intake for this person? What sources of water has the person had to drink today? Are there any potential toxins or pollutants in the environment to affect the supply of water? How does the person prefer the water (hot, cold, icy, room temperature)? Any signs or symptoms of dehydration? Safety: Is the person’s safety at risk? Are there potential factors for the person’s safety? Is the patient hard of hearing or having visual problems? Is the floor cluttered or wet? Are there toxic chemicals in the environment? Is the person under the influence of drugs? Hygiene: Is the person able to care for self? When was the last bath, shower, or linen change? Are the linens damp or wet? What are the environmental factors that affect the person’s hygiene? Is oral care being completed? When was the last clothing change? How is the person’s skin integrity? Pain: Is the person in pain? Have the person rate the severity of the pain (0 – 10). What has worked in the past to relieve this pain? Is the pain chronic or acute? Does the person have prescribed pain medications? What else in the person’s environment can be modified to promote comfort (fresh air, water, food, rest)? Sleep: How much sleep has the person had today? What helps assist the person’s rest or relaxation? Are there potential factors in the environment that inhibit sleep (sounds, smells, light)? How has the lack of sleep affected the person’s activities of daily living? Integrating the essential elements of OMEGA-7 in the practical nursing data collection or focused assessment provides the person in their environment the opportunity to “tell their story.”
Sumner College Student Handbook 31
Made with FlippingBook flipbook maker