Need assessment help!

josinda421 · Jun 18, 2009

Be_Moore said:

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!

I love the way you went systematically. That way you don't miss anything. If you don't mind I would live to save this for my own future reference.