Need assessment help!

Be_Moore · Jun 17, 2009

It will come with time, don't worry! It's a lot of stuff for a new nurse, but organization will come. I personally make my own sheets in a Stenopad book. At my hospital, we do report in a very structured way, so I also write things down in a structured way.

The first things we say are name, age, code status (full code, DNR, etc), allergies, admitting Dx., and medical history. "This is Mr. X, a 59 year old gentleman who is a full code with no known allergies who came to us on the 10th of June diagnosed with pneumonia. Mr. X has a history of HTN, COPD, CHF, a triple-CABG 2 months ago, and CAD, and acute on chronic kidney failure." Abbreviations will be your friend.

After that we go through a review of systems in a structured order.

1. Neuro: "Mr. X is AAOx3, PERRL, moves all extremities with mild weakness needs assistance to the bedside commode but repositions himself. Complains of pleuritic pain in his right lower chest." Pain counts as neuro.

2. Cardiovascular: "Mr. X has an 18g in his right AC and an 18g in his left forearm, getting normal saline at 125ml/hr x 3 bags, the bag hanging is his second bag so he needs one more. He mostly runs in a sinus rhythm in the high 90's, occasional uniform PVC's noted. He'll get tachy into the 120's with exertion or pain. He has good pulses, +1 edema to BLE. He's been normotensive and afebrile." If you don't work on tele, don't worry about his cardiac rhythm.

3. Respiratory: "Mr. X is on 3L of O2 via nasal cannula and sats in the low 90's. Goal is 88-92% SpO2 because of his COPD. Lungs are clear on the left, coorifice on the right, diminished bibasilarly. He desats when he sleeps, possibly a little bit of OSA action, but he comes right back up."

4. GI/GU: "Mr. X is on a low fat/low cholesterol 2gm Na+ 1500ml fluid restricted cardiac diet with Nepro supplements TID. He eats well, voids into a urinal with good yellow urine with no sediment. His last BM was yesterday morning, abdomen is soft/nondistended/nontender to palpation, BSx4."

5. Skin: "Skin is completely intact, he repositions himself." If patient has a pressure ulcer, or wound, talk about it here as well as dressing changes.

6. Labs: Anything completely out of whack, mention here. "His white count this morning was 22, which is down from 29 yesterday."

We always give report the same way, and I write it down the same way on a piece of paper in that order. Because we report in this order, I also assess in this order and before I leave the room I do a mental checklist. If will take a little bit of time for you to remember how your assessment forms/computerized assessment is set up.

I don't necessarily recommend that you do it that exact same way, but you are more than welcome to until you find a method that suites your needs best! It is important to note that our assessment flowsheets follow this order as well, so it's only logical for us to do it this way.

And as far as when a patient codes, just bring the chart with you as well as your stenopad...on the floor there's no way you are going to remember all that information about all of your patients...that why you right it down! Good luck!

Delirious · Jun 17, 2009

I also remember my first weeks as a new nurse having to go back in the rooms to check on specifics as I was charting on my patients. I created for myself a detailed spreadsheet which I would be glad to e-mail you (or post to this site if someone can explain to me how :)). I actually haven't looked at it now in months because I'm familiar with the computerized charting which we use at our facility. Yes, you are normal and it will come with time.

VORB · Jun 17, 2009

I find myself looking at the patient through the "chart's eyes".

Is their IV access where the nurse said it was? Verify their IV fl settings (and make a mental note of when that bag may go empty). What do their dressings look like? Do they have SCDs/TEDs on? Air mattress? Drains/catheters? Oxygen? Pillows under one or more limbs? Verify their last bowel movement. What's their pain level? Any nausea/numbness/tingling/dyspnea? Any visitors at the bedside? Are they aware of the scheduled procedure tomorrow morning (and their NPO status if applicable)?

Jot these things down as you chat w/the patient. Takes maybe 2 minutes per patient if you've got a heavy pt load. You're doing an abbreviated head-to-toe w/emphasis on their chief complaint/diagnoses. In other words, don't assess a 19 year-old w/tibia fracture the same as the 65 y.o. w/HTN, CAD and COPD. Then you can sit down and plan who'll be medicated first and what your priorities will be.

It'll all come with time, and after having to return to pts' rooms enough b/c you didn't write something down, you'll learn what you need to write down to work smarter.

swirlygirl · Jun 17, 2009

Your organizational skills will get better with time! Just take your time and when you chart, just try to picture yourself in the room and remember what you saw. Try to visualize the patient from head to toe. When I first became an RN, I had a wonderful preceptor who was very organized and I still do alot of the same things that she did. About 3 years ago I switched from a med-surg floor to a post-op floor and I had a hard time at first. There were nights I would have 3-4 colon resection patients in a row so that made it kinda confusing. So I made up my own little flowsheet that I use for every patient. It's very specific to surgical patients, and a few of the nurses that I work with have made photocopies of it and use it themselves. I have no idea how to post it here, but I could try to e-mail it to you if you like! Just let me know!

erin01 · Jun 17, 2009

Gosh I am so envious of how you guys have this down! I just am so overwhelmed and I know it has to come with time. I am really trying and my preceptor kind of mean. She is a bit of a drill sergeant but she is a good nurse and I am trying to absorb everything she says. But there so much stuff!!!! I cried after my first day, just so overwhelmed by it all and she is not very comforting at all. She also told me she has made people cry=( But she has a lot of knowledge and its just her personality. And I have learned a lot already. thanks everyone for the info=(

Cherybaby · Jun 17, 2009

No shame in writing everything down as you go. Definately carry a notepad with you. Keep a cheat sheet with lab values, normal parameters and common drug specifics. Remember to prioritize. If you can, refer to the chart before going into a patients room to familiarize yourself with what has happened with that patient up until this point. Then, while everything is fresh in your mind, chart what you have observed.

This may slow you down some, but eventually, you will get your flow. That comes with time and experience.

Good luck to you!

nursej22, MSN, RN · Jun 17, 2009

It will get easier, it takes practice and repetition. Do you remember the first time you drove a car? How overwhelming was that? But you got through nursing school and you can get through orientation.

Establish some routines (you have to do something like 13 times before it's a habit). I like the idea of following the way your charting is organized, that way as you chart it will reinforce what your assessment routine.

There are tons of report cheat sheets on allnurses, try a search.

Next time you feel like crying, it's time for a break!

You'll get through this, millions of us have!

Daytonite, BSN, RN · Jun 17, 2009

I had the same problem when I first started. I started doing a head-to-toe assessment because it was what the hospital recommended and what I could remember. Eventually, it became my regular routine. The hospital had a laminated sheet on how to perform it that it placed in the front of the nurses notes section of each chart for us to follow. Because I was on a cardiac floor we got a lot of people with chest pain and we had standing orders for what to do. Because I would realize all the things I had messed up that I needed to assess when I would sit down to chart, I finally sat down at home and created a check list for myself that I typed out (no computers in those days) and laminated between two pieces of clear contact paper. I still have it. When I worked on a neuro unit I had the same problem with patients who had seizures and would forget to look at my watch to time the seizure at first and then note exactly how the muscular motions proceeded. You learn with experience.

With today's computers you can create your own customized assessment list. Attached is the report sheet I used at my last job and I took report on the blank section of the blocks.

I printed out a new sheet each day before I went to work. I have a collection of a lot of other report sheets I have saved from other posts on allnurses as well. On post #4 and #12 of

Report Sheet (2).doc

VORB · Jun 17, 2009

After you've been at it awhile, it's best to come up with your own note sheet on the computer and make copies at work as needed.

I happen to work the same 3 nights each week and usually have the same pts all 3 nights, give or take. So my sheet allows me to write their basics ONCE plus 3 days worth of vitals, accuchecks, etc. I can fit 2 pts per 8.5x11 this way with plenty of room left over for freehand (new orders, etc). It saves a lot of time when you don't have to copy their particulars at the start of each shift and you can keep using the same sheet all 3 nights.

ssing45 · Jun 17, 2009

Whe I first started I had 12 patients on a tele floor so you can bet that I got organized quick. Make yourself a template then copy it for your reports. I used to use a large legal type sheet but you can work it on a regular size, plain white. Make equal size parallel lines (about an 1 - 1 1/2 inch apart) from one end to the other lengthwise with a space for each patient. Leave a couple extra for admits. You should be able to place a pt sticky label on the line on the left hand side (does your hospital have them?). Write the room number on the sticky label and then fold the right side end across the front to right next to the sticky label, leaviing the sticky showing. Then can then fold it again. Now, what you have is an organized sheet for All you info. Each fold, using front AND back, goes from top to bottom and so you have several columns. Each column can be assigned one use ALL the time so you know right where to look. Now open it up again...column one can be diagnosis allergies and special need (fall prec, q 2 turn etc). Column 2 can be medical history, 3 & 4 labs and tests, if you fold it you over again you will see two more columns per person, you can make those a to do list. You can even fold it one more time for one more column. If you fold this paper up into the columns and then in half it willl fit right in your pocket. Use fine tip pens and you can really write small to fit a lot. You can also use one of those 4 color pens which will organize you even further. When I worked the floor I also carried my tools ALWAYS, I would stick scissors and tape over the tip of forceps and hook them to my pants. Also always have alcohol wipes. You'll get it. The first year is the hardest. I'm rooting for you.

VORB · Jun 18, 2009

ssing45 said:

Use fine tip pens and you can really write small to fit a lot.

I used to like to use fat-tipped pens - the fatter the better. But I now use the fine tipped ones to great effect - especially on those tiny report sheets and with presbyopia issues. Recently discovered the Pilot Ultrafine .038 G2 gel pens. Oh my gosh, it's like a pinpoint with ink. I like click pens versus capped, as it's easier to deal with using one hand (as we always have to do). It's amazing how every little thing contributes to increased or decreased productivity. Pens! We still paper-chart, so it's a big deal - especially filling in those tiny spaces in the chart.

Need assessment help!

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