Assesments...

Who knew that a nurse did a assessment every single time they came on shift for every single patient they were assigned to? Not me!

First Step: Meet the Patient

Knock , perform hand hygiene, introduce self, check the name band on the patient, ask how he or she would be like to be addressed, see if they are alert, oriented x3 (person, place, time), ask about the pain level and when last pain medications were given, check IV site and tubing along with the solution, rate at which it is flowing (usually in mL), check the oxygen, check any other tubes or drains, perform vital signs (blood pressure, pulse, respiration, O2 sats, pain, and temp), safety check(bed in lowest position, breaks on, side rails x2, call light in reach).

Whew! and that was just the first step.

Next check the system that involves the patient's medical diagnosis.

Then comes the Head to Toe. which means that you check every single part of the body and I mean every single part. Leave nothing out! From the head to the toe literally. You also ask the uncomfortable questions. No one ever wants to ask those questions.

After all that the assessing is done.