Head to Toe Nursing Assessment Form for Med-Surg/Onc./Hematology

[saramorris78]

Hello,

I am a new nurse and am looking to obtain a quick head to toe nursing assessment form that I can carry around with me. I am on a Med-Surg/Oncology floor where there is also a lot of patient care for hematology patients (especially sickle cell). If anyone has a checklist or form/ cheat sheet, I would greatly appreciate it. Also, any general advice is appreciated.

Thank you!

[Sonjailana]

How do you chart? Most places I've seen have a general med surg form. I generally ask heme/onc pt's about chemo side effects (mouth sores, skin issues, diarrhea, constipation) and overall pain/nausea control. I make sure when I first assess them to also let them know the plan for the day more than other patients and update them on labs (if they're interested). I try to give an estimate of when chemo/tests are going to happen etc, and give them as much control as possible. Often these patients are more independent for us but stuck in the hospital longer, so I try to make sure all needs are met..and go a little extra..like, do they need a haircut, when was their last thorough shower, do they want to go outside today, etc.

[sportsgirlly]

I got this "nursing assessment checklist" from my med/surg clinical instructor and it has really helped!! Hope it helps you too!

There are a few things that I don't cover with all my patients (ie: the genitalia section, but this could be useful in L&D).

Nursing Assessment Checklist.pdf