Nursing Assessment
By: Kathy on: 2017-04-21 00:39:36

Everyone is assessed by an RN, and/or a LPN.  This assessment will cover every system of your body.  Depending upon your nurse’s experience and time allotted, your assessment can either be thorough or hurried and incomplete.   This the first time your wishes and history are recorded.  (It doesn't mean it will be read).  But it is important to get it done correctly if you ever go to court over your care.

Once your assessment is complete, a care plan will be created from the information on the assessment.  Afterward, it is placed in the back of your charts—rarely to be glanced at ever again.

 

 

Body Systems:

 

Cardiac:

 Your nurse should listen to your heart with stethoscope.  If you brought cardiac strips they should be attached to your chart at this time.  You will be asked about your cardiac history and medicines and pain.

 

Respiratory:

Your nurse will listen to your lungs.  Your 02 sat will be taken as well.  Your respiratory history and medicines as well as shortness of breath and pain.

 

Neurological:

You may be given a mini mental exam and a neuro test.  You will be asked about your memory, dizziness and headaches.  Caution:  you may be categorized on your whole visit based on this one visit.  It is a big deal, especially if you are not in your peak condition.  While this is necessary to have done on admission, you may want to be reassessed later to get a truer picture of you.

 

GI:

This assessment includes your abdomen and bowel status.  Your diet will be discussed, including food preferences and allergies.  Your nurse will listen to four areas of your abdomen, listening to your bowel sounds which may vary in pitch and intensity.  You will asked about your stool habits.

 

Urinary:

You will be asked about pain and any problems you may have, you may be asked to give a urine sample.

 

Skin:

Your entire body should be checked.  Wounds will be inspected and measured, scars noted as well.

Reproductive:

 These areas will be inspected and any questions should be asked in a respectful manner.  Be sure to be candid about infection and discharges.

 

Ambulatory:

Your gait and balance will be inspected.  Be sure to discuss pain or weakness so a plan can be put in place to improve this.  In fact, this should be a main focus for any facility.  Tell your nurse of any history of falls.