If you've already done an assessment on a real live patient, then you have already learned that they don't work in the real world like they did in nursing school
. When I think of the unbelievable detail we went into in nursing school...sigh...we should be so lucky to have enough time to assess ROM on all major joints! Individual fingers! Wow. Sticking with head-to-toe is a good start (that is, don't get distracted from one system to another). Keeping your patient focused also helps, because they tend to want to leap in and tell you what's on their mind. If you stick with the head-to-toe format, though, you will eventually get to whatever it is they want to talk about. When I was in nursing school, I made a cheat sheet that reflected the documentation system of the hospital I was in. That way I could make really quick notes using symbols or circling pre-printed words on the sheet so that I wouldn't forget the details that I knew for sure I was going to have to document later. As for how to do the documentation, it's definitely best to do it as you go, if you are talking about general documentation for the whole shift. You don't want to stop your assessment in the middle to chart what you've looked at so far, and then come back to finish doing your assessment. But if you wait until the end of the shift, you'll forget stuff, that's just how it is. Plus, what if there's a change in status during the shift, and you have nothing documented from the start of the shift? You don't want to have to explain that.
In my experience, there's no substitute for real experience. Practicing on friends and family didn't help because it didn't even come close to mimicking the environment of a hospital. You'll get used to all of it over time, and develop a pattern that works for you. Here's what I do and it works for me:
1) "Good morning, Mrs. Jones. I'm Susan, I'm going to be your nurse tonight. Can you tell me your first and last name please? And your date of birth? Thank you." I'm checking the armband as the patient responds. Don't worry about calling them by name and then asking their name. If they genuinely aren't oriented to person, they won't remember the name you just called them.
2) "Can you tell me today's date, please? That's right, and can you please tell me where we are right now? That's right, and can you please tell me what it is that brought you in to see us? That's my understanding, thank you." Now I know her orientation and have talked to her enough to know her LOC. "Are you having any pain tonight?" This will help make sure you don't do something painful to them in your assessment, as well as direct more detailed assessment of a particular system as needed. It also tells you your 6th VS
3) "I'm going to shine my flashlight in your eyes for just a minute now. Can you please look over my right shoulder? Thank you. Now follow the tip of my flashlight with your eyes. Thank you." PERRLA, hearing.
4) "If you could lean forward for me please, I'm going to give a quick listen to your lungs. Could you take a couple of deep breaths please?" Posterior lung sounds. "Thank you, you can sit back now. Can you please give me a couple more deep breaths?" Anterior lung sounds. "Thank you, just one more now, I'm going to get in under your right arm here. Thank you." RML sounds. "Do you feel like you're breathing okay lately? Yes? Great."
5) "I'm going to listen to your belly now, you can breathe normally for this part." Before my stethoscope actually reaches the belly, I say "Are you having any abdominal pain?" so that I know this before I start messing with them. Assuming no, I listen. "Thank you. Now I'm going to press in a little bit. You'll feel pressure but let me know if you feel any pain." While I'm palpating the abdomen, I say "When is the last time you had a bowel movement? Today? Great. Any trouble urinating recently? No? Great. Any nausea or vomiting? No? Great. Your appetite's been good? Yes? Great."
6) "Can I have your hands for a minute please?" Check pulses.
7) "Now I'm going to check your feet and see if there's any swelling." While I check for LE edema, I'm also checking pulses. "If you need to get to the bathroom tonight, are you able to do that on your own, or do you think it would be best to have some help?" Their answer, coupled with shift report, lets me know if they'll need help with this. It's not the same as assessing gait or mobility, but this is the part where they tell me they are weak, or their left leg cramps up at night, or whatever. (I always stress that we really don't want them to fall while they're here, and it's not their usual environment, so if they feel like they would like any help at all, please please please call, even though of course I secretly hope they don't need the help, but I definitely do want them to call if they do need the help). Best would be to have them get up out of bed and let me see them walk, but the reality of life on the floor usually doesn't allow for that. Sometimes they are up and I can see, and at some point during the shift I'll see if they can get up or not (this is a good argument for not charting assessments *immediately*, although you can always go back and made additions or corrections).
8) If I know or suspect or have been told the patient has mobility issues, I will ask them to roll to their side so I can check out their skin on the backside. Oh boy, never take anyone's word for this one! You can't even rely on asking the patients, they don't always know when they have a pressure ulcer starting.
Unless I'm spacing something big, anything else I do is driven by their diagnosis (e.g., if I know they're in for chest pain, I'll ask about SOB on exertion and circumstances surrounding the pain). I know we always had to listen to heart sounds in nursing school but we did not assess or chart heart sounds on the general medicine floor where I ended up working. If heart sounds are relevant to a particular patient's diagnosis, the MD is following it. This may be different on a cardiac floor or tele floor. Pretty much anything I need to chart, I can pick up from having done the above assessment. And all I have to think about is my introduction, which by now rolls of my tongue without my thinking about it (and I consider all of those orientation questions to be part of my introduction) and then 4 points: eyes, lungs, abdomen, feet. I usually forget about radial pulses until after I've done the feet, I'll be honest about that, but checking the pedal pulses reminds me. Keep in mind you don't have to specifically be asking about a particular body system in order to be assessing it.
Okay, I've gone on too long. Hope some of this is useful to you!