Adult Female Written Assessment

Recently I wanted to give my students a good example of a complete head to toe assessment of an OB patient but was unable to find one on the internet so I typed one up. I would like some help with critique please leave comments to make this a better assessment I am going to work on more assessments for males and females in different age groups. I think that every nurse should be able to write a good complete head to toe assessment I find that I am lacking in this area so I would like feedback. I am requiring my students to write a complete assessment in class, so that they have practice before they are out in the real world. Thank you for your help in advance.

25 year old female pt of Dr. X laying semi fowlers in bed, polite and well groomed. A&O x4 (person, place, time and situation), answers questions appropriately pt denies allergies. Pt states that she is here for routine OB visit, at 37 weeks G3 P1 AB 1s L1. Head: clean hair, well kept, facial features symmetrical, clear speech, PEARRLA, no drainage from eye or ears, mucus membranes moist and pink, teeth in good condition, no observed mouth ulcers. Neck supple, without palpable nodes, no vein distention, pt able to move head in all directions well. Lungs clear throughout, symmetrical expansion with inspiration, no rubbing heard, no cough as also denied by pt. Heart S1 S2 heard, no mummer, strong distal pulses radial, dorslas pedius. Breast symmetrical, without dimpling, or skin lesions, areola symmetrical nipple without cracks or lesions. Pt able to move arms easily, firm equal grips, no edema noted. Abdomen Gravid, although soft, non tender, bowel sounds x 4 quadrants, pt denies constipation, diarrhea, or painPt denies urinary symptoms, denies urgency, frequency, or dysuria, non palpable bladder. Genital Symmetric, no lesions, sterile vaginal exam 1-2 cm, 50% effaced, -2 station. Able to move all lower extremities, 1+pitting edema, 2+pedal pulses. No skin lesions, turgor normal for age.

Deena,

As a nurse you will be able to always get a job, weather it is a job that you want or not is different now. You may have to move to find the job you want or take a job that is Ok in the area that you want to live in. If I were you and wanted to stay in the same community I would take the job, work in the area that you have accepted the job in but keep your eyes open for an area that you want to work in. While keeping your eyes open do the best job that you can, put yourself out there go above and beyond. Your reputation will persuade nurse managers to offer you a position when an opening occurs.

I would also email, call, or introduce myself to the OB nurse manager. I would ask her when another NRP course is going to be offered, ask if you could attend it, you might not get paid for it but you might not have to pay for it. Also watch out for continuing education in the general area of OB, women’s health, Breast feeding, or any area that in some way applies to OB. Do not shy away from any education that the hospital offers you. Continuing education makes you more valuable to the organization and marketable to any other hospital. Keep certifications current even if you are not currently working in that area.

Keep your options open you just might find your niche, even if it is not what you originally wanted.

Someone asked how you become an OB nurse.

Well here is the long and short of it, your first hurdle is to get into RN school. If you are a nontraditional student, a student on a budget or someone who wants to finish in a shorter amount investigate Technical colleges or two year schools, although be careful some states are attempting to require four year BSN prepared nurses. If your state does not the Tech school is a less expensive. I completed my RN degree in 18 months; this was a great blessing to me and my family. I attended a technical college in GA although I lived in FL I was close enough to receive instate tuition. After I finished school I was able to start working in the ER were I worked before nursing school. The knowledge I gained in the ER was invaluable giving me a broad range of experiences to draw from. 18 months after I finished the RN program I started a RN to BSN program. This program took 16 months to finish. The time line of the two programs allowed me to finish both degrees before I got burnt out.
Although I was able to continue to work during both programs most Generic RN students are not able to successfully complete an RN program while continuing to work even part time. I had a husband that was beyond supportive; he cooked, cleaned, and washed all the laundry. All that I did was make sure we had cold drinks in the frig.
I did not do anything special to better my résumé to work in OB. I could have taken NRP to increase my chances but that is usually offered to new employees after the hire date. While you are in nursing school you might seek employment at a hospital to gain valuable experience although it is very hard to work and go to school. If you have any questions please leave a comment.