Every patient is assessed by an nurse upon admission. This nursing assessment will cover every system of the body. This is the first time your loved ones wishes and history are recorded.
There are two parts to the nursing assessment. If an LPN is deemed competent by the RN the LPN can do the one part. This assessment will cover every system of your body. Depending upon your nurses experience and time allotted, your assessment can either be thorough or hurried and incomplete. Every RN has to have their first job, and your family may very well be one of their first patients. In college the RN will likely have clinical experience in a hospital, but that’s not true in every college. They may be receiving training from the LPN.
This the first time your wishes are heard and your history recorded. It is important to get the nursing assessment done correctly if you should ever go to court over your care. Your care plan will be made upon the information in your assessment. A family may request a copy in writing, but most likely will only be allowed to read certain parts of it with a RN or LPN watching. The facility will most likely tell you they are there to help explain medical jargon; however it is so you don’t take pictures or remove parts of the chart. The nursing home may make copies of only the parts they are willing to let you see.
Depending upon your specific illness or problems, the nursing assessment should take at least 2 hours. It may take more for instance if you have several wounds to measure and dress, or a long cardiac history. Based upon the assessment the nurse may ask the doctor for more lab work, scans or x-rays
Body Systems and the Nursing Assessment:
Your nurse should listen to your heart with a stethoscope. If you brought cardiac strips, or EKG’s, showing their heart rhythm, they should be attached to your chart at this time. You will be asked about your cardiac history, medicines and pain.
Your nurse will listen to your lungs. Your 02 saturation, which shows how well your body is using the oxygen you are breathing in, will be taken as well. Your respiratory history and medicine list will be written down, including notations about any shortness of breath and pain you are experiencing.
You may be given a mini mental exam and a neurological test. You will be asked about your memory, any dizziness and headaches. Caution: you may be categorized on your whole visit based on this one set of questions. It is a big deal, especially if you are not in your peak condition when this assessment is taking place. While it is necessary to have this done on admission, you may want to request a reassessment later to get a truer picture of who you really are.
Categorization means how the nursing population will think about you. It will not be written down, however passed on between nurses. They may say, this one is a drug seeker, or has a history of beating his wife. These things can make a difference in how the nurses view and treat a person.
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, and to your bowel sounds which may vary in pitch and intensity. Your nurse will ask about your stool habits.
You will be asked about pain and any problems. You may be asked to give a urine sample.
Your entire body should be checked. Wounds will be inspected and measured, scars noted as well.
These areas will be inspected and any questions should be asked in a respectful manner. Be sure to be candid about infection and discharges.
Your gait and balance will be inspected. Be sure to discuss pain or weakness so a plan can be put in place to strengthen you. In fact, this should be a main focus for any facility. Tell your nurse of any history of falls.