assessment

[hope4thebest]

I will be starting my clinical stage in med-surge, so my question is: what does the client's assessment consist of? (either general, basic or specific)

[Daytonite, BSN, RN]

are you saying you haven't had anything about this in your nursing program at all? or, are you just kind of thinking ahead and wondering what the assessment is all about?

there are lots of weblinks on this thread:

https://allnurses.com/forums/f205/health-assessment-resources-techniques-forms-145091.html - health assessment resources, techniques, and forms (in nursing student assistance forum)

you can also get history and review of systems information on this form:

[attach]5444[/attach]

[fleur-de-lis, BSN, RN]

Sometimes it depends on what the instructor wants, but at a very minimum when I walk into a patient's room as a student, I look at

1. Level of consciousness - do they respond to me when I introduce myself, and are they oriented x 3?

2. Listen to heart and lung sounds.

3. Check IV site and see what is running and at what rate.

Then I go from there depending on what I find. Sometimes we have to fill out a full head-to-toe assessment that spells out what you need to assess, but if not, this is the minimum I feel comfortable doing, knowing that I am partially responsible for the patient's well being!