I’ll be completely honest with you. I had absolutely no idea what a nursing assessment was when I started nursing school. I knew nurses asked you a bunch of questions when you go to the doctor. I knew they gave shots, meds and took blood pressures. But that’s basically where my knowledge ended on the topic. Yikes! Obviously I was super prepared to become a nurse.
I have a feeling we’re a lot alike in this way (don’t worry, I won’t tell anyone.) That’s all changing, right here, right now!
Why it’s the Bomb-Diggity:
The nursing assessment is truly the single most important task that nurses (and nursing students) do. It helps us develop a plan to get the patient better, evaluate our interventions, and alert us to serious problems.
Without it, we would just be taking blind guesses at what is wrong with our patient and hoping that one of the interventions we try works. Doesn’t sound like a good plan does it? I know that I wouldn’t want to be that patient!
Gross Anatomy of the Nursing Assessment:
The assessment process is a strategic way that we can examine a patient and collect the data we need to plan their care.
The nursing assessment really has four components:
1. General Survey
2. Health History
3. Physical Assessment
Each of these components is really deserving of it’s own little book, as there is just so much that goes into them. Maybe one day I’ll muster up the gumption to write that? For now though, let’s stick with this.
Over the next few weeks I will cover each topic involved in the nursing head to toe assessment.
Make sure to download your FREE General Survey Cheat Sheet that goes along with this post. Print it out and take it to class, lab and clinical, and get ready to ROCK the nursing general survey!
The general survey is your first impression of the patient. This includes data like their appearance, mental status, behavior, mood, pain level, speech, mobility and body type.
Questions to ask yourself:
– Are they easily awakened?
– Is the patient well groomed?
– Do they look older/younger/or about the same as their stated age?
– Is their face symmetrical?
– Are they responding appropriately?
– Is their speech delayed or stuttered?
– Are they calm or agitated?
– Are they thin or overweight?
Questions to ask the patient:
– Can you tell me your name?
– Can you tell me where you are right now?
– Can you tell me what day it is?
– What brought you into this facility?
– What’s your pain level?
– What’s the quality and location of your pain?
– How do you normally get around (cane, front wheel walker, independently, etc.)?
Look around the room:
– Is the patient safe in the position they’re in?
– Do they have IV fluids running?
– Look at how many mL are left (think ahead to when you’ll need to grab a new bag of fluids).
– Is their bed alarm on?
– How many rails are up on the bed?
– What’s their bedside table look like?
– How many mL of juice did they drink since documented last?
– Is there anything in front of them that shouldn’t be (cigarettes, thin liquids if they are on a nectar thick diet, etc.)?
This is the general survey in a nutshell.
Download your FREE general survey cheat sheet so you never miss a question again!