Assessment Experts!!

1017sharonrn2003 · Jul 2, 2005

I agree that sometimes it seems assesments are quick. But there are nurses who do great assesments everytime. I personaly wouldn't feel like I was doing the pt justice to just skim over the assesment, anyway, here's what I do at the hospital I work for. After report, I check labs and any progress notes that may be vital. I go and meet the pt, I typically talk to the pt, if they're able, and ask about pain, how they slept, etc. Then I tell the pt I'm going to be listening to heart and lung sounds. I start with the heart. I first listen for irregularities, murmors and such. I also use both the bell and the diaphram of the chest piece, because as you know, some heart sounds are best heard with one side or the other. I listen to the heart from all aspects, not just in one place. After that, I take an Apical pulse on everyone, I listen for one complete minute. I then record my findings on my pt sheet. I then listen to lung sounds anterior, if possible, I have the pt sit up for better distrubution of sound. Then I listen to the lateral fields, then the posterior-bases are most important. I place the stethascope (spellings not my thing) on the pt's skin, we have germicidial that kills just about everything where I work, so I clean after/before every assesment. Wile listening, I'm also inspecting the skin for color, lesions, etc. I ask questions to pt about their breathing: pain, difficulty taking a deep breath, dizziness, etc. Of course, then I document findings. Then I go to GI,Gu and so forth. I do all systems and I take no short cuts. Yes, it takes me longer than some to get through my assesments, but I know I did what I needed to do for the well being of my pt and I can pick up slight changes quickly. I'd love to share more with you and give more detail, if you want you can e-mail me . I think one of the most important things we can do for our pts, is to give them a great assesment every time. I wish you luck and happiness. :nurse: