HA! I was working fast track and read some of the fast track patient assessments by one of the RNs.....
A/Ox3. Hx of Cdiff. Recent blood noted in stool x8 hours.
Fell yesterday in ED. Presents today with hip and knee pain bilaterally.
Believes she may be pregnant due to multiple positive UPT's
Those were examples of our RN assessments today in Fast Track.
Our hospital also makes all RN assessments simple check boxes for different body systems. Click Click Click Assessment complete.
When you're running around like a chicken with your head cut off, you could write out a very detailed assessment in the flow-sheet, or you could get to doing orders and use the check boxes. /sigh.... somedays, i feel assessment skills fly out the window
I get mad props on my assessment skills in my ED and I moved into my second year of ER nursing. A good generalized written flow sheet assessment could even go like this.....
"Pt presents to ED with c/o..... (why pt is here) x (how long s/s persisted).
Pt ranks discomfort / pain a (#/10).
(Insert focused assessment- ie: use your head to toe assessment skills learned in school but focus only on that one system)
Pt Hx includes....
Bowel and bladder question
Call light in reach. Pt voices understanding of current plan of care. Family at bedside.
So to make one up off the top of my head....
Pt presents to ED with c/o worsening RUQ abominal pain x 3 days. Pt state pain is "consistent & sharp, like it never goes away" pain ranking 9/10. Pt denies previous Hx of current c/o.
Bowel sounds are normo-active x4. Abdomen is soft and non-distended. Tenderness upon palpation per pt in RUQ.
Medic line 20G LAC. 150 mL NS successfully infused by medics. Infusion discontinued upon arrival to ED. Pt seen at St. Jane Doe ED last night for similar s/s. Pt Dx'd with bladder infection.
Pt denies dysuria, urinary frequency, hesitancy, anuria, or pain upon urination. Pt denies fever, chills. Pt professes to outstanding hx of ovarian cysts, commonly treated with Norco Rx. Last menstruation stated to be approximately 1 week ago and WNL per pt.
Pt states BMs are WNL and denies dark tarry stools or bright red blood.
Denies chance of pregnancy.
Call light in reach. Family at bedside. Pt voices understanding of current plan of care.
The assessment included
1. primary complaint (HOW LONG and complete with a SUBJECTIVE DESCRIPTION as well as if this c/o is something NEW or OLD.)
2. Nursing assessment
(notice its similar to your GI assessment in your head-to-toe assessment)
3. Hx leading directly up to current ED visit.
4. Previous medical Hx for pt
5. always ask about urinary and BM outputs because they factor into almost every system in one way or another.
6. Pregnancy does F-ed up things to the body, so might as well ask, particularly if u suspect a CT or Xray.
7 Call light in reach. Family at bedside. Pt voices understanding of current plan of care