Assessments?

[manna, BSN, RN]

I just can't seem to get the hang of assessments. Sounds stupid, right?

This is my 2nd clinical semester, and I'm willing to admit that I seem to be a much more academic than practical student (I'm great with tests and understanding the information, it's just doing tactile things that I have difficulty with - does this mean I'm doomed as a nurse?) :chuckle

We did a big, huge assessment video last semester for part of the final for

our assessment course. It lasted over an hour and was incredibly thorough... but honestly, do you really do a 12-point neuro check on every patient? Or all of the ten or so different eye exams? *sigh*

My problem is - we weren't really taught how to focus assessments, or if

there is a "baseline" assessment that you do on everyone. Consequently, I go

into my patient's rooms and get confused and can't remember what I should be doing other than the basics like VS, breath and bowel sounds, etc.

Anyone have any advice? Cheat sheets you use? Hints? PLEASE? :chuckle

[mom2michael, MSN, RN, NP]

Cut and paste this to a word processer of your choice. Highlight things you'll do all the time, make each line colorful so you can see it at 1st glance. Adjust the font and size and get it to fit on a smaller piece of paper. Laminate it and stick it in your pocket. Pull it out when you go to do an assessment and you can follow it from top to bottom.

Head-to-Toe Assessment - Initial Survey: Check ABC's

LOC (Awake, alert/lethargic/unresponsive)

Orientation (to person, place and time)

Neuro check (PERRLA/Glasgow Coma Scale if appropriate)

Skin color (pale/pink/ruddy/cyanotic/dusky)

Skin temp (cool/cold/warm/hot)

Skin texture (dry/diaphoretic)

Skin lesions/pressure or statis ulcers/ecchymoses: color, drainage, odors, LxWxD in cm

VS - T (include route), P, R, BP/5th VS = PAIN

Apical-rate, S1, S2

Rhythm (regular/irregular/regularly irregular)

Intensity (loud/distant)

O2 and Pulse Ox

Effort (easy/unlabored)

Depth (deep/shallow/blowing)/Auscultation-ant/lat/post

* Chest tubes/need for suctioning/advanced skills, i.e. tactile fremitus/diaphragmatic excursion if applicable

Upper extremities - if IV present note: gauge, solution, rate and infusion pump/controller. Assess IV site for: warmth, redness, edema, drainage or tenderness.

Abdomen - inspect (round/flat/obese/distended)

* Any PEG, G-tube, NG-tube, Dobhoff tube?

Auscultate (BS present x 4 quads? rhythm of BS - normal/hyper/hypoactive and the intensity - high/low-pitched)

Palpate (soft/firm/hard/tender to light and deep palpation?)

Abdomen (continued)

Bowel: Last BM (size/color/consistency/odor)

Postop flatus?

Incontinence - urinary or fecal or both?

GU: Void/ Foley/ Suprapubic/Fr and balloon size, amount, color, presence of mucus/sediment, odor. Note patency and describe urine in dependent drainage bag tubing.

Ostomy? (note condition of stoma and skin surrounding stoma/contents of ostomy bag-phalange or bag change/client's adaptation to ostomy)

Lower extremities -

Homan's sign (negative/positive) - with positive being a bad sign possibly indicative of DVT.

Pedal pulses (Dorsalis Pedis/Posterior tibial, compare bilaterally, Grading (0 - +4)/check for edema) - pitting (+1 - +4)/nonpitting?

Capillary refill (brisk/sluggish-how long, >3 seconds)

ROM, Gait

Dressings, drains or wounds should be assessed and documented in the order they appear in the assessment - i.e. RUE ā RLE. If a circulation check is done, place that information in the order it was assessed.

Circulation Assessment, include: color/warmth/pulse/ capillary refill/movement and always compare bilaterally.

Client Education: Include how client learns best, teaching done and client response.

[manna, BSN, RN]

Thanks very much! :)

[WSU_Ally_RN, BSN, RN]

Does the hospital you are at use a tri-fold flow sheet to record assessments on? I always just go by that, and take it in the room with me until I get the hang of the particular floor's assessment. That is what their baseline assessment is.