i'm glad you are asking before you see the patient!
the information you get from your assessment is the foundation of your entire care plan--i'm not kidding. the questions you ask are your assessment of the patient.
don't misunderstand this activity. it is extremely important. your assessment consists of
- the information you get from your interview of the patient
- your physical examination of the patient
- the information you get from your examination of the patient's medical record.
there are a number of resources to help you with this on the student forums. they will guide you in the questions to be asking the patient. most of them are on the nursing student assistance forum in sticky threads.
- https://allnurses.com/forums/f205/he...ms-145091.html - health assessment resources, techniques, and forms (in nursing student assistance forum) - has all kinds of links to various types of physical assessment tools and instructions.
- taber's cyclopedic medical dictionary - has a 7-page nursing assessment tool in the very center of the dictionary listed under "nursing". you can use it to help you as you sit with and question the patient.
- if you look at the bottom of my reply you will find a link to a word document that you can open and print out that says student clinical report sheet for one patient. it has review of systems information in the lower 2/3rds of the form that you can use to ask the patient about.
- https://allnurses.com/forums/2228927-post5.html - this is a listing of the important information you need to collect from the patient's medical record (chart)
something that many of the above do not address is adls (activities of daily living). make sure you ask the patient in a tactful way how they are able to accomplish eating and drinking, toileting, bathing, dressing, ability to move and get where they need to go, communicate, sleep and rest, work and diversional activity. we nurses are big on helping patients with their adls, so don't forget those.
now, your care plan is totally dependent on the abnormal data
that you get from your assessment. so, it's important that you know what the normal response should be to the questions you are asking. you are always wanting to be alert for the patient having any difficulty or problem accomplishing their adls. for physical assessment it is pretty easy to pick out abnormal data. for example, lung sounds should be clear. if they are not and you hear wheezes, then wheezes become an abnormal assessment data item that you use to help you in choosing a nursing diagnosis. in most cases you will find that the patient will be normal in most things, but there will be a few things that will not be what we consider "normal" and those things then become the problems which will form the heart of your care plan.
a care plan is nothing more than a problem solving process. thus, your assessment is a hunt for problems
. don't let the nursing diagnosis part of it freak you out. a nursing diagnosis is merely a fancy label for a problem the patient has. just like a doctor puts a label called a medical diagnosis
on a patient's set of signs and symptoms, we nurses put a label called a nursing diagnosis
on a patient's set of signs and symptoms as well. the nursing set of signs and symptoms differs a bit from the ones physicians come up with. nanda has given us a written taxonomy (an arrangement, or ordering, of the nursing diagnoses into a logical grouping) that describes, at present, 188 nursing diagnoses, or problems. all you have to do is match your patient's signs and symptoms (the abnormal data you collected during your assessment) with the nursing diagnoses that will apply to him. don't make it any harder than that. you will need a nursing diagnosis reference book of some sort to help you do that.
you will need to know a bit about the patient's medical disease/condition to help you understand what the doctor's treatment plan is. keep in mind that the doctor has also done an assessment and made a medical diagnosis
. the doctor is treating the patient's medical signs and symptoms. you will also be treating some of the same signs and symptoms because they will be forming some of your nursing diagnoses
. you must know what the doctor is doing and why. i just posted a long list of internet links to some helpful websites where you can find some of this doctor information on the diagnosis and treatment of all kinds of medical diseases. it is at
when you are ready to start writing your care plan you can find information at:
or post a question and i will help you.
if you still need help setting up your list of assessment questions, ask. good luck with this first assignment. please don't be discouraged. it takes many, many patient interviews and assessments to become very skilled at this. you learn and improve from each one you do. the important thing is that you dig in and do the activity. try not to be too terribly formal with the patient. be tactful in the way you ask questions. when i got "lost" i tried to keep a picture of the body in my mind and work from head to toe as i asked questions. for adls i visualized what i did as i went throughout my daily activities and asked questions that went along with those activities.