Nursing assessment help!!!

[savy0727]

HI, im in my second quarter of clinicals and i am still having trouble actually talking to patients. I have always been very shy and i know if im going to be a nurse i need to crack out of my shell. for our assessments we have to do like a patient interview where we ask a bunch of questions related to like sexual reproductive system and religion belfiefs, like elimination, history, and all that. my problem is i have a hard time knowing what to say and how to say it. if anyone could provide like a list of questions to ask or choose from that would be great i have searched online on google and all i can find is how to do the head to toe, doesnt say anything about actually talkin to the patients i know that should be common sense but im just not good at it. somebody help me please. lol

[CardiacKittyRN]

In the hospital, its really not realistic to ask EVERY single question you see listed in the textbook for an assessment interview. I always start by looking at a patient's chart, seeing the chief complaints & medical dx, and then focusing my assessment as needed. As with religion and things like... hm.. I've never actually done a "spiritual assessment" (as our fundamentals book called it), but I can see where you might want to do that in certain situations. However, first I'd build up a relationship with the patient.

As for other questions, just ask as you go through the assessment. For example, before you listen to their abdomen ask if they've had a bowel movement today, if not when was the last time, anything abnormal? Or if when you listen to their lungs - ask - any difficulty breathing? SOB? If their coughing - any sputum? If so, what color, consistency, any blood? Pain?

The conversation should just flow with the assessment! And don't get caught up in asking everything from the book. Just ask what you need to in order to have a thorough assessment without playing 50 questions w/ them. lol. Hope this helps!