Help With Assessment Narrative

[goldpk]

Hi everyone! I'm getting ready for my last semester of nursing school which makes me pretty nervous. Our critical care rotation is no joke (or so I've heard) and I've already lost a lot of friends from failing out of the program. We had an assignment over the break...

Complete (and record) a 5-7 minute head-to-toe assessment with a partner (which I've done) then document a narrative head-to-toe assessment just as you would in a chart. This is the part I'm not sure how to go about ...I would ask my instructor but he's pretty intimidating and they're going to give us "extensive feedback" on the narrative so I just want my first shot to be really good try. Any advice? How long should it be? What points need to be addressed?

Thanks in advance!

[THELIVINGWORST, ASN, RN]

Do you have a nursing documentation book? An assessment book will illuminate the subject for you.

[nurseprnRN, BSN, RN]

The way I found easiest in practice was to start at the top and work down. I am assuming she'll give you some sort of medical dx so you can do a focused assessment.

Subjective: (whatever the patient can communicate to you)

Objective:

(Head) Neuro/CNS-- level of consciousness/orientation (BTW, LOC does not mean "decreased level of consciousness), special senses if applicable, paralysis/paresis/reflexes/sensation, etc. Pain/meds/results

(Chest)

Cardiovascular: EKG, pulses & waveforms, BP, heart sounds, JVD, anything else applicable; IVs/vascular access, vasoactive gtts/CO/SVR/PVR etc. Daily weight compared to yesterday (best indicator of fluid balance) and I&O. Hematology labs.

Pulmonary: effort of breathing, breath sounds, RR, vent/settings/pressures, ABGs; chest tubes, wounds, other suchlike

(Abdomen)

GI: bowel sounds, NPO/appetite/tolerated/BM, any tubes/access and what's coming into them or out of them (NG, gastrostomy, jejunostomy, ileostomy, colostomy). Wounds. GI labs.

GU: u/o, color, specific gravity, Foley/void/etc. Renal labs.

Extremities/Integument

Extremities: color, movement, capillary refill for feet and toes, hair distribution, nails, wounds

Psychosocial:

Behavior/feelings/coping, visitors

Note that you can double up some of this stuff-- all the while you're doing physical assessment, you can be assessing level of consciousness, pulses and skin temp, wounds, etc.

With a little practice (and I would start now) you can do a pretty good focused initial assessment in ten minutes.

[RubberDuckieLove]

What assessment forms have you used in the past during your clinical rotations? We use a form for our head to toe assessment. I would use that as a guide. If you don't, I agree with GrnTea, start with the head and work your way down. I always start wit neuro and end with my pedal pulses.