[massou]

Can anyone help me? I need help with assessments of patients. Also, I am told that I am not asking questions that new graduates normally ask. What type of questions should I be asking? Thanks!

[traumaRUs]

I moved your post to a new thread so you would get more answers...good luck.

[al7139]

Hi there!
I am not really sure what you are asking. It sounds like you are having trouble with assessments, as well as asking questions of your preceptor.
I will say that I have alot to give you. I graduated in May 2007, and took a job on a tele unit right out of school. I had done clinicals on this unit as a student, and liked the staffs eagerness to help us, and I did not feel like a burden, like I had on other units. I actually applied and got hired on this unit before I graduated based on recommendations from my instructor (who is a PCS at the hospital) as well as staff that I worked with. It was kind of odd, because I never thought I would enjoy working on a cardiac care unit, and always thought I wanted to do ED/Trauma. I have found that I am very happy where I am since then, and am glad I chose this place to start.
To (I hope) answer you questions:
1. Assessments: First rule is to always do your own...NEVER go with what you got from the previous shift. I will turn patients to look at their skin, listen to their lungs, heart, etc. And I look at them from head to toe...don't be embarrassed about private parts! Lots of times a CHF pt will not show any other sign of fluid retention other than a swollen scrotum, so look! Explain to the pt why you need to see all of them, and what you are doing each step of the way, but do it!
Also, assess often. If you have a pt you got vitals on 3 hours ago, but you have to give a B/P med to or a diuretic, etc. Check those vitals and apical pulse again right before you give the med! This is so important, because the pt can bottom out if you don't. Lots of docs give parameters (i.e. "Hold lopressor if SBP is <100 or pulse is <60), but even if there are no parameters, check anyway, and if you have a doubt call the doc. Keep in mind that lots of assessment is subjective, so what you see as +3 edema may be +2 to someone else. The main thing is to assess early in the shift, and keep an eye on what to look for to determine if there is a problem (for example; a pt who presented for chest pain...are they pain free? are their lungs clear? what does their telemetry strip say? Remind them to call at the first sign of discomfort).

Out of all your pts, who is the sickest? What do they require for care?How often do you need to assess their status? What can you trust to the ancillary staff, and what do you need to do yourself?

Uncover all dressings and assess wounds. I had a report where I got that the pts rear was red, but intact, and when I turned them, they had a stage II...How many shifts had that been missed?
I could go on and on about assessment, but th ebottom line is to do your own thorough assessment, and document what you see. Also assess frequently those really sick patients.

As far as what questions you should be asking...
ask lots of questions! Don't be afraid to be a pain. That is how you learn, and most staff understand that you are new and need to ask questions so you can learn. My pharmacy and the telemetry monitors know me by name because I am always calling to ask them stuff (is this compatible? Do you see an abnormal rhythm?). My preceptor was great, and I could ask her anything, and even now that I am on my own, I ask the other nurses if I have a question...
You are not annoying them, you are learning...Even the experienced nurses on my unit ask questions! After all, you will never learn everything as this profession is constantly evolving.
Hope this helps.
Amy

[Spatialized]

You're asking a pretty broad couple of questions. Like mentioned above, what part of assessments do you need help with? Is the finer points? The overall feel? As for questions, most new grads have nothing but questions (which is a goo thing!). But I'll take a crack at it.

1. Assessments
Get a look at them literally from head to toe. Leave no stone unturned. Focus on trouble spots for that particular patient while getting the whole picture. Admitted for CHF? Lung sounds, edema, exercise tolerance urine output. Arrhythmias? Look at perfusion, do they have good distal pulses, adequate urine output, is their mentation normal, how does their heart really sound - regular, irregular, split sounds, rubs.
Never, ever take what the previous shift said for granted...sure it is a baseline that you can determine who is the sickest to see first, but do your own, folks have nasty habit of getting sicker at shift change sometimes.
The telemetry is also a vital part of your assessments. Print your own strips for your patients and analyze them. What's the rate, rhythm, and intervals? Figure the QTc, especially if they are receiving drugs that may prolong or alter that (Tikosyn, Haldol, Seroquel to name a few). Don't rely on your tele tech if you have one to tell you what is going on, see it for yourself and use them as a resource as you need. They know the rhythms inside and out (usually) adn can give you an idea of what the patient was doing previously.
Many floors have techs/CNAs doing vitals, but we do our own and I think it adds to our assessments. It gives you a clear, current picture of what is going on with your patient while you are assessing them. Personally, I've been doing most of my vitals manually, I've come to not trust the machines and your ears are the best way to find a BP on someone with an arrhythmia.

2. Questions
It scares us nurses when new grads don't ask questions. We know that there is no way one can know everything right out of school and folks who think they "know-it-all" can get in over their head quickly to the detriment of the patient. There's not a night that goes by where I don't ask at least one question. Usually it is thinking out-loud, bouncing ideas off my co-workers or just a knowledge deficit (or I can't remember something). A lot of the typical questions revolve around situations giving a med or not, what's the rhythm, having an issue with the patient, should I call the doc or wait; things like that. Maybe you've got it all figured out, that's great, but we all run into situations that are foreign to us, it's more likely to happen with new grads than seasoned nurses though.

Good luck!
Tom