Table of Contents
An introduction to a Comprehensive Nursing Assessment
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Some of the following is only for Crit Care/ICU/ED environments. But to be thorough, most ward nursing should include most things in the below table.
Some other articles you will enjoy
- For a comprehensive and systematic approach to assessment in ICU, read THIS POST
- For a guide to placement/grad year on a cardiac / cardiothoracics ward + free worksheet on cardiac pharmacology and main cardiac issues go HERE
- The ultimate nursing guide to sepsis
- A cheat-sheet guide for your cardiac nursing placement
- The helpful complete guide to an Aged Care Nursing Placement for students
- 14 strategies for successful clinical placements
- Untangling nursing communication – “My patient can’t talk to me… Help!”
- Step-by-step explanation of nursing CPD
- Helpful list of proven graduate nurse tips!
- You MUST know about ACT-PINCHES (N) drugs
We recommend you have a read and if you’re a student then you print this off and take in your bag to re-look at as a prompt. With the invention of online progress notes on EMR, some nurses will have a document on the computer they copy and paste the subheadings and then fill in their progress notes to not forget anything.
We hope you like this post. If you are about to start work in ICU or are a student going on placement then check out THIS POST on what to do to prepare for work/placement in ICU.
Fast Hugs in Bed Please
We have also had a reader link us to Life In The Fast Lane concept known as FAST HUGS IN BED Please, which is a rapid assessment tool for identifying supportive care needs. Read the post HERE
Complete Assessment
Presenting C/O
Phx
Social Hx
A)
B)
C)
D)
Progress:
Plan:
| Systems | Assessment |
| Neuro/CNS | GCS Pupils Sedation Headache Blurred Vision Slurred Speech AVPU RASS Temperature Investigations: CTB Reflexes Seizures Limb Strength Facial Droop Aphasia/Dysphasia |
| Cardio/CVS | ECG analysis Heart Rate BP Medications (cardiac ones: digoxin, statins, GTN) Access: IVC, PICC (where, size) CVC (where, lumens, emergency drug port) CVP Arterial Line (where) Chest pain Palpatations Heart Sounds Investigations: ECHO, Angiogram Troponin Electrolytes IVT Pulses Central and peripheral CAP refil Diaphoretic Colour Bleeding |
| Respiratory | Chest sounds CXR analysis Air Entry O2 sats RR WOB SOB NIV NP/HFNP/Hudson mask/NRB Investigations: CTPA, VQ Scan Intubated RSI for intubation Ventilator observations and settings ETT size and lip level Grade of intubation ABG/VBG ICC Co2 |
| Gastrointestinal | Bowel Sounds Pain or tenderness on palpation NGT Bowels opened Bowel chart and information Colonoscopy or other scopes Investigations: AXR, CTA NGT Feeds D & F NBM Vomiting Diarrhoea Pregnancy Mouth care |
| Renal | Urine Output IDC Bladder washout Dialysis Fluid Balance Chart FWT |
| Metabolic | ABG Analysis BSL, Ketones Insulin |
| Skin | Pressure sores Wounds Dressings Wound Chart Lacerations Grazes Sutures Staples Plaster of Paris Back slab and crepe Colour Pressure Area Care TEDS IVC Drain tubes Use of air mattress Hygiene – bath/shower |
| Social | Lives with Visitors Family Meeting Domestic Issues |
