General observations made during the initial assessment of a patient include their appearance, mobility, ability to communicate, and cognitive function. Use this table to evaluate your general assessment skills and how you record your findings. If you identify areas you are shallow in, and then make the appropriate adjustments the next time you record patient care.
Guidelines for General Observations
|After examining the respiratory system, document the following:|
|Assessed||Rate and rhythm or respirations|
|Auscultated||The lung fields|
|Inspected||Sputum for color, consistency and other characteristics.|
|After examining the cardiovascular system, document the following:|
|Auscultated||For heart sounds|
|Assessed||Heart rate and rhythm|
|Assessed||The color and temperature of the extremities|
|Assessed||The peripheral pulses; record the quality by “number”|
|Inspected||For edema (pitting; record by “number”)|
|Inspected||The neck veins (distention)|
|After examining the neurological system, document the following:|
|Inspected||The patient’s head for evidence of trauma|
|Assessed||The patient’s level of consciousness, including orientation to time, place, person and situation|
|Assessed||The patient’s ability to follow commands|
|Assessed||The patient’s pupillary reactions and cranial nerve function|
|Assessed||The patient’s extremities for movement and sensation|
Top 5 Malpractice Claims Made Against Nursing Professionals
Chances are at some point in your career, you will either:
- Have a claim made against your professional services.
- You will be named in a group lawsuit – whether as part of a larger group of health care professionals and/or included with your health care facility.
- Witness a negligent act by another health care professional during the course of a normal work day.
- Be deposed to testify on behalf of yourself, your employer or colleague.
No matter what the situation, being involved in any allegation of malpractice can be emotionally and financially devastating for all parties. However, if you are specifically named in the malpractice suit, your asset, reputation and career could all be in jeopardy. It is important to understand the most common allegations and how they happen in order to minimize your risk. Most malpractice calms involve at least one of the following allegations:
- Failure to follow standards of care
- Failure to use equipment responsibly
- Failure to document
- Failure to assess and monitor the patient
- Failure to communicate.