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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.

First clinical as an instructor

Now I went through clinicals, I was told about the dress code. Slacks no jeans, dress shirt no tee shirt, and dress shoes. Well yesterday I accompanied 9 students to a clinical orientation. I was speech less, out and out speechless, of the nine students one, yes one, only ONE was dress appropriately. Did you get that ONE was dressed in business casual. 7 were in Jeans, one in sweats, when I saw the first in jeans I thought great I will have to send her home. Then I saw the rest and I thought how could I send home 8 student nurses? Now this is not all their fault I will take 50% of the blame, I didn’t think to explain to them what business casual was, that jeans were not appropriate. So I will mark this one down as a learning experience for me. I don’t think that they realize that during their clinical experience every time they are in a facility they are on a job interview. I think that some nursing students take clinicals too lightly they think that they are just buying their time until the graduate. What they fail to see is that the nurses that are working on the floor when they are a student are the same nurses that they will be working with when they finish school. I know of an instance where a student nurse was let out of a contract because they could not find a unit that would accept her based on her clinical performance as a student nurse. So be careful when you are at your clinical sites.

What has been going on.

Hey All
I have not posted in such a long time, not because I don’t have anything to say it is just because I have not taken the time out to post. I have missed posting. To catch you up on what is going on in my world, first I finished my BSN!!!!! Wow I am so glad to be done with that. I had a wonderful Christmas with my mom here, and my little girl she had a great time opening all of her gifts. So in January the hospital I am working for decided that they were over budget by a great deal and have cut hours, so instead of getting my 36 hours a week I am now getting 32 hours a week. Since my budget is not use to that reduction and I feel very uneasy about the economy right now I have started to pick up as much time in ICU as they will let me have which is about a day a pay period which is enough to cover the time lost. But I was not sure that I would get that time because if there are not any patient in the unit we take call, which is nice but not as much as four hours of pay. So I received an email at work for an LPN instructor at a Tech school close to my house so I thought well hell I could apply it never hurts so I did, they called me in for an interview and the lady said that I they had one more to interview so I thought that there wasn’t a chance for me to get that job but low and behold they call me to teach. I started last Monday I will be teaching on Mondays, for eight hours. So I am treading water with working about 38 hours a week at the hospital 8 hours teaching and three classes toward my master’s degree.
I am excited to be teaching I really enjoyed my first class, since I was kind of hired after the quarter started it is like I am a sub, but I think that if I continue to teach that next quarter will be better I will have some experience, it is OB, and I will start it off.
The master’s program this semester is tough I have research, theory and policy so they are all thinking classes, where I actually have to apply my knowledge instead of just regurgitate what I already know.

GA Board of nursing Licensure by Endorsement

Statement from the Georgia Board of Nursing
“Important Announcement Concerning Statutory Changes to RN Licensure by Endorsement in Georgia

During the 2008 session of the Georgia legislature, a bill was passed that requires all applicants for licensure by endorsement to have graduated from a nursing education program approved by the Georgia Board of Nursing or which meets criteria similar to, and not less stringent, than those established by the Board. This bill went into effect on July 1, 2008 and is codified in O.C.G.A. §43-26-7(c).

The Board takes seriously its duty to protect the public health, safety and welfare and the duty to ensure that nursing curricula should meet stringent, board-approved standards required by the recent changes in the law. Applicants for licensure by endorsement must graduate from schools whose curricula are no less stringent than those standards established by the Board. The Board is not unsympathetic to the plight of the students who have been adversely affected by this new law, but the Board has a duty to uphold the law and is currently doing so.

The Board has established rules that state the requirements for board-approval for nursing education programs. These rules can be found on the web here (See Chapter 410-3, Nursing Education Programs): http://rules.sos.state.ga.us/cgibin/page.cgi?g=GEORGIA_BOARD_OF_NURSING%2FNURSING_EDUCATION_PROGRAMS%2Findex.html&d=1 The Board may waive rules, but only when doing so will not contradict the law. If the Board waived a rule so that applicants whose education did not meet board criteria are issued a license, the Board would be breaking the law and endangering the public’s health, safety and welfare. The Board has a mandated duty to protect the public under O.C.G.A. § 43-26-2, which states, “The purpose of this article is to protect, promote, and preserve the public health, safety, and welfare through legislative regulation and control of registered professional nursing education and practice. This article ensures that any person practicing or offering to practice nursing or using the title registered professional nurse, as defined, within the State of Georgia, shall be licensed as provided in this article.”


As nontraditional student I am acutely aware of the need to have the flexibility in class scheduling. As a nurse I understand that there are a large number of nurses who will be retiring in the next 10 years increasing the nursing shortage. The number of new grads is considerably less that the number of current nurses leaving the profession. The safety of our patients needs to be addressed with either issue lack of nurses or lack of experience in the field. First of all we need to investigate innovative ways to recruit and retain high quality nurses. Second of all we need to protect our profession and the skills require in order to have a safe and effective practicing nurses.
This bill states that in order to apply for a nursing license by endorsement that you had to have graduated from a school with a comparable curriculum to those with in the state of Georgia. This means that schools who do not require clinical hours would have to change the set curriculum to include clinical hours. Currently there are schools that advertise No campus attendance, No waiting list, and Academic Success Guaranteed. I don’t know about you but I had to apply to nursing school, I waited and waited to find out if I got in, they only took so many students, there were qualifications that each student had to meet. Once we got in we were not guaranty academic success, we had to work for our grades, we had to pass test, and we actually had to know the information being taught we did not pay for our grades. As a nursing student I could fail if I did not know how to place a foley using sterile technique, give a medication correctly, or complete a sterile dressing change just to name a few. As a currently practicing RN I have no problem having students follow me, precepting a new grad, or assisting a coworker in a new procedure, but I understand that they have some basic knowledge and have practiced somewhere before they come to me. I am all for nontraditional schools, providing education to student nurses I just feel that there should be some standards for all nursing schools part of that being clinical hours.
Please leave comments on you opionin I want to here from students who have graduated from some of these nontraditional programs tell me why they are just as good as schools who require clinical time. Let me know if you think that student nurses need clinical time.