Inpatient Nursing Assessment
Assessment is one of the first and one of the most important skills a nursing student must learn.
There are many aspected of assessment and there is definitely more than one way to do a physical assessment. However you do your physical assessment it is important that you develop a systematic approach and use this with every patient encounter. This not only helps you to be thorough but it is also easier to remember if you have a routine that you follow each and every time.
There are many "cheat sheets" to be found and it is always important to perform assessments in accordance with your school and/or facilities' guidelines. Here's one "cheat sheet" which gives a very basic idea of what a should consist of:
However, many of us are visual learners and a video speaks volumes for me also. It can't be overemphasized that consistency is the key. When you get your system down, doing it repeatedly is what makes it stick. Also, it should be mentioned that many times we do a more focused assessment that does not include all of these parameters. Again, important to comply with your school and/or facilities' guidelines. Most will have a set order and procedure for what they are going to check off. Hospitals and other facilities might not have a specific order or even require a complete physical assessment. For instance, you might do a complete assessment upon admission for a patient undergoing a total knee replacement but then immediately post-op you would focus on their operation site, vitals, respiratory status and neurological status. There would be no need to examine their genitalia unless their was an issue.
About traumaRUs, MSN, APRN Admin
Joined: Apr '00; Posts: 52,468; Likes: 25,150
allnurses Asst Community Manager, Advanced Practice Nurse; from IL , US
25+ year(s) of experience in Heart Failure, Nephrology, ER, ICUSep 24, '17Short, concise, accurate. Thanks for the article, Trauma. Should be required to register on AN.com, especially for students.
I admit I watched with the the youtube speeded up to 1.5X, and with the exception of waiting the full minute in the absence of bowel sounds (and other time-based metrics, to include breath sounds), THAT's the way it actually goes (depending on the pt's ability to cooperate, of course)! Short-staffing For The Win! (avoided text/chat speak there).
N.B. I am NOT suggesting anyone should shortchange any time related components of an assessment in any way.Sep 28, '17I have to confess I cringed when she told the patient she was going to go ahead and "take your pulse and assess your respirations" -- but then she said in an aside NOT to tell the patient..!