Initial assessment

Assessments are hard to be "cookie cutter." Each patient is different, so you are going to have to approach each patient different. The way they teach you in nursing school is just a general guide, that way when you are out in the real world, you won't feel so lost and you will know what objective and subjective information to look for.

I have been on many types of units but the assessment has been the same. Start by asking how they slept and if there is any pain. Right there you can get airway alertness and orientation. then I listen to heart, lungs and abd. then proceed to the pulses in all 4 limbs while checking for swelling then look in the mouth and check IV sites. You will need to find you own way to assess but make sure you cover it all.

I have been on many types of units but the assessment has been the same. Start by asking how they slept and if there is any pain. Right there you can get airway alertness and orientation. then I listen to heart, lungs and abd. then proceed to the pulses in all 4 limbs while checking for swelling then look in the mouth and check IV sites. You will need to find you own way to assess but make sure you cover it all.

sounds like a good system, and I like the orientation check at the beginning. I would add in skin assessment and of course any other tubes or lines they may have besides an IV. I also want to know when they last had a BM.

The mistake I see nurses make is concentrating on the primary diagnosis and missing other things that a general head to toe assessment will show. For example, if your patient is post-op with a femur ORIF, don't just look at that hip incision.

If by "cookie cutter" you mean that all assessments are the same, head-to-toe, then you are right... and wrong. If you go into a patients room and that patient is in respiratory distress, then that is your first priority, is there an airway, what is the SaO2, is the pt. on O2? what is the flowrate, the heartrate, etc... Once the pt. is settled, then you do your head to toe - and good things about how to do that have prevously mentioned. You will also learn how to incorporate several assessments at once... if they smile and talk to you, then you can notice if their facial expressions are equal, or is there a droop on one side, are they oriented?

Don't be alarmed! These are learned skills, not something you will be able to do in your first semester, and maybe not even right after graduation. It takes time to be able to know what you are looking for, what you are looking at, and how to be able to put it all together. There are RN's who only do focused assessments, that is they only look at the ORIF hip, and not the rest of it. Why is that a problem? Well, what if the ORIF hip now becomes SOB and develops chest pain? If you haven't done a thorough assessment you won't know what the patients baseline is, and you have nothing to compare their current status against.

It is all a learning process, and you will learn to put those cookie cutter pieces together and take wonderful care of your patient! At least, this is what I tell myself everyday I go to clinical or to work! :wink2: