Hope you had a great week. Today we want to talk about one of the most important jobs a nurse has. Assessing your patient. This post is more about when you finish nursing school and are working the first time on the floor of a health care facility. I bring this up mainly because of an incident that happened with my niece a few days ago. When she started work, we had a long talk and she asked me for some tips on working in the real world. One thing I told her to do was to always thoroughly assess her patient at the beginning of the shift. Don’t take the word of whoever was giving her a report from the previous shift but to go and check out her patient. Take the time to speak with them (if they’re able to talk). Turn them, make sure nothing is under them and everything is OK.
She told me that one of her patients she was assessing and pulled the sheet back to assess the pedal pulses. The patient had no legs. She looked back into the chart and all of the nurses prior to her had said that the pulses were fine. That is sad.
Here are some tips for doing your assessment.
- When I worked I always did my assessment head to toe, that way I didn’t forget anything.
- Talk with your patient as you’re doing the assessment. Ask them how they’re feeling. Do they feel better or worse? If they’re feeling worse then ask them how. I had a patient in ICU once. An elderly patient. I worked the 7pm to 7am shift. Her vitals were stable, assessment showed nothing remarkable. When I talked to her something was ‘off’ that I couldn’t put my finger on. I was a new nurse, had only been in ICU for a few months. I called the doctor, told him that something was ‘off’, he laughed at me. I told him that he should come in and see her, he shrugged me off. About midnight that night she had a heart attack, so the doc got to come in anyway. He never doubted me again when I told him something was up.
- If you don’t write it down, you didn’t see it.
Here is a good review of an assessment – http://nursinglink.monster.com/benefits/articles/184-how-to-perform-a-head-to-toe-assessment
I hope you have a wonderful weekend!