Patient Assessment

New nursing graduates will need to perfect the skill of performing a complete head to toe assessment.  As a preceptor in the Intensive Care Unit, I highly recommend that this becomes second nature to nurses no matter which area of the hospital they work in or which facility they work in. Should the patient go into cardiac arrest, you will have to use ACLS protocols to initiate care. The head to toe assessment is crucial in helping the nurse identify any concerns that may arise for his/her shift.  Have a sheet of paper and do the following:

Neuro:
alert? oriented? pupils equal, round, reactive to light, accommodate? responsiveness to painful, noxious, tactile stimuli?  arouse to speech or voice?  any posturing noted with nail bed pressure?  facial grimacing?  follow commands?
Cardio:
Any murmurs auscultated ?  S1S2? Cardiac Rhythm?  any ectopy noted? heart rate normal?  regular or irregular? any chest pain, or pressure?
Respiratory:
Lungs Clear? diminished bilaterally? crackles? rhonchi? wheezing? stridor? dyspnea? is the rate regular, shallow, fast or slow? oxygen needed? Pulse oximetry? If on the ventilator (know the vent settings).  You will need to know the settings to help make any changes to the vent, based on the ABG (Arterial Blood Gas) when the results are available. Should the patient require Pediatric Advanced Life Support, you must be prepared.  If on the vent, perform frequent mouth care to decrease the risk of Ventilator Associated Pneumonia.  Suction as ordered or per hospital protocol.
GI:
abdomen soft, round, distended, hard, tender?  bowel sounds?  Present in all 4 quadrants? tolerating diet? nausea or vomiting? If the patient has a Nasogastric Tube, what color is the secretions that are in the canister?  How much secretions, or blood?
GU:
is the patient incontinent, diaper, foley catheter? can they void on their own? monitor the amount of urine per hospital protocol (ICU may be every hour), difficulty urinating? burning or pain when urinating? Monitor the color of the urine, any sediment, odor, cloudy, hazy, hematuria, tea-colored, etc?  monitor the foley catheter per hospital protocol.
IVF (Intravenous Fluids):
In this section, it is recommended that the IV site is noted, the type of IV it may be, such as a peripheral, Central venous Catheter, PICC line, etc.  and record the types of fluids that are in the patients room,  record the rate, any infiltration noted? swelling, redness or tenderness at the IV site?  Follow hospital protocol in reference to how often the facility would like the IV site to be changed.  And in another section, record any lab values, vital signs or  the times that medications are due, and any new events for your shift that will need to be reported to the next shift nurse.

This is just some ideas to help the new nursing graduate to be more organized and focus.  If the patient can communicate with you appropriately, listen to the patient.  It is their bodies and they know more than anyone how they feel.  It is not up to the nurse to judge whether or not the patient is truly experiencing pain or discomfort.  Pain is whatever the patient says it is.

Keep the patient and family updated on the plan of care and any concerns that they may have.  Being able to educate and bring knowledge to the patient or family about their condition will ease an enormous amount of fear and anxiety.  From experience, I have found that if the patient and family are informed about what is going on with their diagnosis and condition, the calmer they are.  Put your self in their place or even sometimes picture the patient as a loved one, you would want the very best for them.