dsb05220 541 Views
Joined May 9, '08.
Posts: 2 (50% Liked)
I have been where you are now. I have 6 weeks left in my program. I just start from the top and work my way to the bottom.
Example of general assessment:
A&OX3, Apical pulse Reg at 80bpm. Lungs clear and equal Bi-lat. ABD soft, and non-tender. Bowel sounds acitve. (+) pedal pulses, (-) pedal edema bi-lat lower extremities.
I go in to more detail in certain body systems depending on abnormal findings or diagnosis.
A&OX2 oriented to person and place only. Apical pulse irregular at 110bpm RN notified. Crackles bi-laterally, diminished at the bases. Occasional cough produces moderate amounts of yellow sputum. O2 sat 90% on 2 lpm via NC. Resp 12 and unlabored. Patient denies shortness of breath or dizziness at this time. Teaching done about incentive spirometer use. ABD soft and non-tender. Bowel sounds active. Trace edema noted in feet and ankles. Thigh high Teds stockings in place (+) circulation, (+) sensation, (+) movement, (+) pedal pulses bi-laterally. Patient denies any pain at this time.
My instructors tell us that we should document any interventions that we do for abnormal findings in our assessment. We also need to document that we notified our co-assign or the MD.
A cheat sheet of possible findings while you do your assessment can also help you when you are writing. Hope this helps!
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