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The assessment



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Oct 05, 2005 07:33 AM

The assessment


Hey everyone-I need some advice on doing my assessments. How can I remember to check everything in one sweep? I usually end up going right back in to check something I forgot. Any tips?


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2 Comments
No. 1
Old Oct 05, 2005, 08:26 AM
Updated Oct 10, 2005 at 11:41 AM by babynursewannab

It's really mostly about developing a routine. Write one down and try to do that by memory a few times and then start with the patients. I'm in the CVICU so I have some "external" assessments I need to do with the machinary as well. For example mine is: Approach pt, say hi, introduce self, check pressure bag for Swan and A-line, Go over and talk to pt a minute (to assess orientation), listen to heart, listen to lungs, listen to bowel, check all inscisions, look for edema, check pedal pulses, feel for coolness/warmth, check all IV sites and skin along the journey then go over and level my patient for the Swan and A-line transducers.

Yours will probably be different. Everyone's usually is.
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No. 2
from Corrin1RN
Old Oct 08, 2005, 03:19 AM

I work in a tele/stepdown unit and graduated 7 months ago. Our assesments and charting are all online so when i started i just wrote down a check list of things to do including the assessment on my clip board. I just go head to toe, while talking to the patient, also I like to do little things that day shift might have been to busy to do on my first stop in the room.
after report, underline all things i need to do or check on with red pen
check med times for night and write in margin of report sheet
check for precaution or npo sighns on door
introduce self to pt and family
check for proper braclets
check ivbag, label, rate, tubing label, iv date
listen to lungs, heart, bowel, check bilateral grips, check radial and pedal pulse, all the while looking at incisions, for edema or bed sores,
pick up room and ask pt if there is anything i can do for them or snack
write small list of things to bring to room on second round into rooms for eack room(iv bag, ice, ambien, lol...), this saves on running up and down hall every time i forgot something
before leaving room, glace back over report sheet to trigger my memory on anything i might have forgoten
if overwhelmed by milions of things to do running around in head, write things down on back of clip board and cross of as i go, minimizes forgetfulness.
while i was learning to do assessments i simply had a head to toe check list written out that i used at the bedside, as you can see i am a list person, but sometimes i think my pt's are comforted when they see me writing down things about them, they seem to know that i am trying to do everything i can to make them comfortable and it makes them happy, and a happy pt, along with plenty of prayer before my shift, usually equals a good night.
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