The assessment

It's really mostly about developing a routine. Write one down and try to do that by memory a few times and then start with the patients. I'm in the CVICU so I have some "external" assessments I need to do with the machinary as well. For example mine is: Approach pt, say hi, introduce self, check pressure bag for Swan and A-line, Go over and talk to pt a minute (to assess orientation), listen to heart, listen to lungs, listen to bowel, check all inscisions, look for edema, check pedal pulses, feel for coolness/warmth, check all IV sites and skin along the journey then go over and level my patient for the Swan and A-line transducers.

Yours will probably be different. Everyone's usually is.

I work in a tele/stepdown unit and graduated 7 months ago. Our assesments and charting are all online so when i started i just wrote down a check list of things to do including the assessment on my clip board. I just go head to toe, while talking to the patient, also I like to do little things that day shift might have been to busy to do on my first stop in the room.

after report, underline all things i need to do or check on with red pen

check med times for night and write in margin of report sheet

check for precaution or npo sighns on door

introduce self to pt and family

check for proper braclets

check ivbag, label, rate, tubing label, iv date

listen to lungs, heart, bowel, check bilateral grips, check radial and pedal pulse, all the while looking at incisions, for edema or bed sores,

pick up room and ask pt if there is anything i can do for them or snack

write small list of things to bring to room on second round into rooms for eack room(iv bag, ice, ambien, lol...), this saves on running up and down hall every time i forgot something

before leaving room, glace back over report sheet to trigger my memory on anything i might have forgoten

if overwhelmed by milions of things to do running around in head, write things down on back of clip board and cross of as i go, minimizes forgetfulness.

while i was learning to do assessments i simply had a head to toe check list written out that i used at the bedside, as you can see i am a list person, but sometimes i think my pt's are comforted when they see me writing down things about them, they seem to know that i am trying to do everything i can to make them comfortable and it makes them happy, and a happy pt, along with plenty of prayer before my shift, usually equals a good night.