How do you write an assessment report?

Nursing Students Student Assist

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HELP!!!

I have to write an assessment report for school and don't even know where to begin. Could someone help me? Thanks.

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Don't they show you in school? Assess what?

We did those all in lab with the "head to toe" assessment but it was given to us written already..all we did was fill in the 'blanks' next to the questions with the proper terminology.

A little more complicated than that but you get the idea.

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Were you given an example or parameters?

I mean I know when I was in school we had to do one assessment that followed The physical examination handbook and we had to cover every system.

daily when I write my initial assessment I just do a brief overview covering the basics and all invasive lines etc.

Alert oriented x3 MAE at will and on command grips = bilat, lungs CTA, mediastinal and right pleural chest tubes to y connector 20cm sx, bowel sounds present but hypoactive, radial and pedal pulse palpable bilat, denies c/o pain at present, R IJ c swan CI 2.8 CO 5.6, L radial artline good waveform coorelating with NIBP, LR@50 to R IJ, foley cath to gravity draining clear fluid, bilat SCD's, L wrist IV HL'd, monitor alarms on. L Leeds RN

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Were you given an example or parameters?

I mean I know when I was in school we had to do one assessment that followed The physical examination handbook and we had to cover every system.

daily when I write my initial assessment I just do a brief overview covering the basics and all invasive lines etc.

Alert oriented x3 MAE at will and on command grips = bilat, lungs CTA, mediastinal and right pleural chest tubes to y connector 20cm sx, bowel sounds present but hypoactive, radial and pedal pulse palpable bilat, denies c/o pain at present, R IJ c swan CI 2.8 CO 5.6, L radial artline good waveform coorelating with NIBP, LR@50 to R IJ, foley cath to gravity draining clear fluid, bilat SCD's, L wrist IV HL'd, monitor alarms on. L Leeds RN

She's in first year LPN school. I dont think it's as complicated as all that. :chuckle

But nice example.

PS: I am not downplaying LPN school...just know we dont deal with alot of what was written yet either.

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She's in first year LPN school. I dont think it's as complicated as all that. :chuckle

But nice example.

PS: I am not downplaying LPN school...just know we dont deal with alot of what was written yet either.

I didn't see her level of schooling listed, isn't LPN school just one year? I know it was when I did it but that was back in 1994!

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Well it's one year up here. Max two if you're in the slower part time program.

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I think im doing this reply thing right. lol. First we fill out a physical assessment form given to us by our clinical instructor. From that we have to write the assessment report. I know she want it from head to toe. However, my problem is, is that i cannot make it sound smooth. Is it supposed to be that way. I am going about it as if i were writing a regular report and i'm not sure if that is right. Well, I am off all week, so i guess I'll work on it and post it to see what others think. Thanks for your example.

Carol

She's in first year LPN school. I dont think it's as complicated as all that. :chuckle

But nice example.

PS: I am not downplaying LPN school...just know we dont deal with alot of what was written yet either.

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CAT tools are what you are talking about. however, we need to take that info and make an assessment report out of it. My problem is that I cannot make it make sense. My resident has PVD. So i started with "R.S. has PVD which effects the circulatory system. He also has HTN in which case his blood pressure is higher than the normal 140/80 (?) he is taking (med here) and is on an NAS diet." Then I have to add the other medical Dx. I get that far and get stuck. And my program 22 months. night school. i graduate July 2006. I hope.

Carol

Don't they show you in school? Assess what?

We did those all in lab with the "head to toe" assessment but it was given to us written already..all we did was fill in the 'blanks' next to the questions with the proper terminology.

A little more complicated than that but you get the idea.

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Specializes in Gerontological, cardiac, med-surg, peds.

I'm sure this is overkill, since it is from a medical school site, but this may be of some help anyway (especially since it is so well organized):

http://courses.washington.edu/medicm/icm2/samplestandardizedpatients.shtml

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my question is for the RN. Could you write out plainly what you wrote in this assessment?

Were you given an example or parameters?

I mean I know when I was in school we had to do one assessment that followed The physical examination handbook and we had to cover every system.

daily when I write my initial assessment I just do a brief overview covering the basics and all invasive lines etc.

Alert oriented x3 MAE at will and on command grips = bilat, lungs CTA, mediastinal and right pleural chest tubes to y connector 20cm sx, bowel sounds present but hypoactive, radial and pedal pulse palpable bilat, denies c/o pain at present, R IJ c swan CI 2.8 CO 5.6, L radial artline good waveform coorelating with NIBP, LR@50 to R IJ, foley cath to gravity draining clear fluid, bilat SCD's, L wrist IV HL'd, monitor alarms on. L Leeds RN

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my question is for the rn. could you write out plainly what you wrote in this assessment?

alert oriented x3(as it soundspatient is alert and and oriented to person place and time) mae (moves all extremities) at will and on command grips =(hand grips equal bialterally) bilat, lungs cta,(clear to auscultation) mediastinal and right pleural chest tubes(this isgnifies placement pleural could be right or left) to y connector(means that both tubes drain to one atrium chest set) 20cm sx,(suction) bowel sounds present but hypoactive, radial and pedal pulse palpable bilat, denies c/o (complaint of)pain at present, r ij(internal jugualr signifies placement of line) c(means with) swan(is a swan ganz catheter for measuring ci cardiac index and co cardiac output) ci 2.8 co 5.6, l radial artline good waveform coorelating with nibp(this means that the arterial line pressure is close to the same as the non-invasive blood pressure), lr@50 to r ij (r & l mean right or left they are circled when using abbreviations, lr is lactated ringer), foley cath to gravity draining clear fluid, bilat scd's(sequential compression device), l wrist iv hl'd(heplocked meaning no fluid running to this iv), monitor alarms on.(in ccu each patient is on a separate monitor this means the alarms are on) l leeds rn pt means patient pt means either physical therapy or in a lab test can mean pro-time.

there you go

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