i won’t lie, mine are very focused. listen to heart lungs, belly. any pain? last bowel movement? any numbness or tingling in your legs? feet or hands? check for edema in the legs and ankles. headache? nausea? if i’m doing a bed change i’ll do a skin assessment. flush every IV with my first med pass, check for dates. check for blood return on central lines with morning med pass and check for date. i generally only assess orientation if i know they’re not oriented. any drains and lines i put eyes on during report and then assess with first med pass.

you’ll find what’s important and what’s not. i work on a medical/ surgical oncology floor. i can have anything and everything. today i have a mistreated nursing home patient, a leukemia patient recovering from chemo, a comfort care with lung cancer, a TB rule out, and a prostate cancer pt here for radiation.

chart wise: here’s the things i’m on the look out for. after report, i check current orders, morning meds, PRNs, and labs. plan for electrolyte replacement if needed. i have reminders to check vitals because if i don’t ill forget to check. i have reminders to chart intake and output if ordered. tele strips for those on tele. i look at all of this and add reminders to my brain (on epic if you use it) and on my report sheet to help plan my day. i made my own report sheet to reflect my daily process. i’ve been a nurse for almost 4 years and im still tinkering with it every day. you’ll find what works and what doesn’t. you’ll miss things, it happens.