assessment help please...

  1. ok, i'm still hung up on assessment questioning, it just seems like an enormous amount of questions to ask. if they have something wrong with one body part/area/whatever, is it still necessary to ask family history, social and personal history, or PMH on EVERYTHING else?

    i know this probably seems like a dumb question, but i just can't get used to asking so many questions, i know no real nurse or doc has ever asked me so many!

    would anyone be willing to type up the questions you routinely ask patients?
    maybe in a few different scenarios?

    it would be immensly appreciated! thanks thanks and more thanks.
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  2. 8 Comments

  3. by   nurseshawna
    **anyone?**
  4. by   colleen10
    You really have to learn to adjust your assessment/questioning to the situation you are in at that moment.

    Anymore most doctor's offices have you fill out a form and just check off what ever diseases run in your family rather than ask you during your visit. Then, while you are doing your physical assessment on the patient you can be sure to pay extra special attention to areas that may indicate the person has that diesease, ie. if they have a family history of thyroid disorder you can assess the gland, ask some questions about weight gain/loss, energy level, etc.

    If you are in an emergency situation, of course you will forgo the family history and concentrate on just the necessary info. needed at that time like what diseases/disorders the person might have, what meds. are they on, etc. Family History can then be done at a later time when they are stable.

    A lot of times people don't remember that, say, their grandmother died of a CVA at age 55. So, you can work it backwards too. If you are assessing a person and you notice that their BP is a bit high you might ask them "has anyone in your family ever taken medications for high BP or had a stroke?"
  5. by   thanatos
    Depends on where you practice. I work E.R. and we just ask for the big stuff, e.g. smoker, lung dz, cardiac dz, diabetes, etc. On the in-patient floors such as ICU and Med/Surg, the nurses have to fill out a very extensive data base upon admission that covers all of the body systems and socio/economic/emotional/financial issues.
  6. by   SCNuttyMeg
    I work on a cardiology floor and and overall assessment is gathered on admissiion such as mentioned in the previous thread about socioeconomic, how independent they are in there adls, financial and then any problems with GI,GU,etc. When i go into a room to assess a patient, I do a head to toe assessment and focus on the reason for admission such as Chest pain...I focus on the pain, sob, numbness, tingling, etc. But i still ask questions pertaining to how have you been eating, passing gas, check out there color of skin, urine, pulses.

    Hope this helps!!! It really depends on the type of patients your working with to know what to ask.
  7. by   Ruylupez
    My instructors would require all of the other questions be asked if time allows. The reason they would give is that people frequently have more than one thing wrong with them and by doing the full assessment you will find ALL of the problems that you may need to know about. Of course in an urgent situation you deal with the immediate problem before going on to the rest of the job.
  8. by   wonderbee
    It's really a critical thinking thing. Think of your own body starting with your head and moving down to your toes. Do you ever get headaches? Ever experience dizziness or loss of consciousness? What kind of headaches... migraines or the garden variety? Do you wear glasses? Any blurriness? Excessive tearing, burning? Moving down to the nose, do you have a runny nose or hx of sinus infections, etc.

    Get the picture? Think of all of the problems you've ever experienced with your own body or possibly could experience. This will probably be flowed from a prepared list of questions in an actual admission setting.

    Hope this helps.
  9. by   LadyT618
    Nurseshawna, I know where you are coming from. I have a whole lotta questions too. Our instructor said by the end of the semester (and as a working nurse) you should be able to ask all those questions (including family history and all that good stuff) in 15 minutes. I think it's possible, but now right away of course. We'll eventually get there. Good Luck!
  10. by   susi_q
    Shawna - I'm assuming that you are a student currently. If that is the case, then we as instructors are wanting you to ask about "everything" so that you get used to looking carefully, and gaining some awareness about the huge variety of "normals". True, once you are a "real" nurse, you won't usually have time to ask every single question ... but you will have all those questions in the back of your mind, and then you will become more aware of the ones that you should ask this time.

    Good luck. It gets easier with time.

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