need help in assessing!

athena55, BSN, RN · Dec 21, 2006

Hello Ishy25:

Below is an excellent link to nursing assessments. Check it out:

Nursing Process & Critical Thinking::INDEX

Anthropometric Data: refers to your patients height, weight, BMI

Vital Signs: self evident (BP, Pulse, Resps, Temp, Pain level)

General appearance: is your patient well nourished? How does she "look" to you? Were you able to observe their gait when they entered the room? How did their hands look to you, when you shook their hand? (clubbing, acrocyanosis, edema...)

Head -- in this category I would include EENT

Heart: cardiovascular status, heart sounds, pulses. Is your patient edematous? pitting/non-pitting.

Pulmonary: again, self evident. Auscultate your patients breath sounds. How is their breathing pattern? Are they using pursed lips to breath? Are they experiencing SOB upon exertion?

GI/GU: GI-- auscultate the bowel sounds then palpate/percuss. When was the last time your patient had a BM (what did it look like etc), nutritional status: what kind of diet does your patient consume? GU -- any problems with voiding?

You would also assess your patients:

Neuro status, skin integrity, PMH (prior medical history): Any history of cardiac, pulmonary, renal, endocrine problems? Do they smoke tobacco? Do they partake of ETOH? Sexual history (are they partnered? Do they use protection against STDs? Any problems?)

Any allergies? DO they take OTC medications or meds not prescribed by their health care provider? Do they HAVE one? (NP, MD, DO, PA)

Do they have an advanced directive?

Now with a wee bit of experience you can get almost all of this information during your initial interview or conversation with your patient.

Perhaps you could ask your professor/instructor for references. Check out Bates or Mosby.

Good Luck!

athena

Daytonite, BSN, RN · Dec 21, 2006

i think these links will give you the information you are looking for:

http://medicine.ucsd.edu/clinicalmed/introduction.htm - click on "write ups" to see two examples of how to write up h&p findings.

http://www.stbarnabashospital.org/fp/sampleh&p.doc - this is a guideline on how the results of a history, review of systems and physical examination should be written up.