Assessment - seriously what are you supposed to do?

CrufflerJJ, BSN, RN, EMT-P · Jun 18, 2009

If you're 6 months away from graduation, and have only passed 1 med, that sounds a bit scary. I wouldn't expect you to hang an IV until later in your program (usually IV meds given by students are very tightly monitored/controlled - at least they were in my program).

If your clinical instructors aren't teaching you much, I'd recommend two things:

- ask your instructor questions you might have regarding assessment techniques

- If your instructor is an arrogant, fault-finding idiot (hopefully not!) & you're reluctant to look "unprepared" or "stoooopid" by asking them reasonable questions, you might ask the nurses on the floor where you're doing clinicals. They may be friendlier than your clinical instructor.

mama_d, BSN, RN · Jun 18, 2009

I'd try and find a nurse on the floor and ask them if you may tag along and watch them do several assessments.

My assessments include lung sounds (posterior and anterior), generally through the gown unless I'm hearing something wonky, then I'll slip the stethoscope under the gown. Bowel sounds in all four quadrants, and abdomen assessment (distended, soft, firm, etc.). Heart sounds, nothing fancy, just listening for normal/murmur/irregular. Check for edema in all four limbs and how far up it goes. Assess for orientation (this is a good time to check and make sure the right armband is on and verify allergies). If they are a high risk for breakdown, I also check heels and butts for skin issues. I don't do the whole pen light in the eyes thing unless they're in with neuro issues, but I do check to make sure that pupils are the same size and round. Check for movement issues...weak on one side, in one extremity, etc. Check the IV site for patency and any issues. I also like to ask when their last BM was, we get a lot of patients on narcs.

I know it sounds like a lot, but once you get a routine down, it only takes about five minutes per patient. Follow up assessments are more focused, mostly just edema, lung sounds, and if any confusion has set in (we get a lot of sundowner patients).

New 2 iceeYouRN · Jun 18, 2009

I can't believe you've never seen a nurse do a real assessment! I've gone through 2 rounds of Med/Surg and am about to enter Critical Care in the fall. I also work in the ICU which is where I have really seen assessments at their best. My clinical instructor has hammered into our brains that critical care is all about assessment! That your patients condition may change in the matter of minutes which is why it's so important to do a thorough head-to-toe at the beginning of your shift.

I agree with CrufflerJJ, you need to talk to someone about this. Find an instructor you are comfortable with, or better yet, stand up and talk to your clinical instructor. If anything he/she will have much respect for you if you're pointing out where you believe you are weak and acknowledging that you want to become a stronger nurse.

Just remember, this is your future you're preparing for. Get the most out of your school, afterall you're paying them.

Good Luck!

JaneyW · Jun 18, 2009

If you have passed med/surg, you should be able to perform a head to toe assessment independently. Is this an RN program? I find your post a bit frightening. Your school is letting you down. Do they have a skills lab? Are there videos you can watch that teach head to toe? I will go out on a limb and guess youtube probably has some decent head to toe videos. Did your text come with a cd-rom with videos? Do not go by what you see on the floor. Hopefully your next clinical instructor will take the time to actually teach you! Until then, try to be as proactive in your learning as possible.

A lot of floor nurses will do a shorter, more targeted assessment if they are familiar with the pt and diagnosis, but as a student you should be doing a complete assessment to find your patient's deficits and know what needs to be done when you care for them. How else do you know what to do?? Good luck to you.

Daytonite, BSN, RN · Jun 18, 2009

first off, i have to say that hiding in the hallway because you're afraid of your instructor is absolutely the wrong thing to be doing. in six months your instructor is going to be your colleague and your equal. at present your instructor is there to facilitate your learning. you should be picking his or her brains or those of staff nurses that are willing to help you. grab them and say, "help guide me through a head-to-toe assessment with this patient and let me know what i am doing wrong or could do better" or "can i watch you do a physical assessment of a few patients this morning?" that is part of their function. if you don't then you will be in the embarrassing position of telling the interviewer when you go for your first job that you've never done one and that you will need instruction in it if you do get hired. it is not necessarily up to the instructors to offer any help, but for you to seek it out because you need this experience since every student's clinical experiences are different and dependent on the kinds of patients they are exposed to in clinicals. when we hired new grads for rn positions one of the things we used to ask of their instructors when we could get them on the phone to talk was, "is this a student who stands in the back and just watches or do they volunteer or ask to do procedures and attempt to learn new things?" we wanted employees who were eager to learn, not milquetoasts. rns have to be leaders and problem solvers and you can't be that by being invisible, afraid of authority figures and reticent to come forward and advocate for yourself or patients.

this is the advice that is given to medical students and some of it is relevant to nursing students as well (from http://meded.ucsd.edu/clinicalmed/thoughts.htm):

never be afraid to ask questions. if those that you are currently working with are unreceptive, make use of other resources (e.g. house staff, students, nurses, health care technicians, staff physicians). you can learn something from anyone.
there is no substitute for being thorough in your efforts to care for patients. performing a good examination and obtaining an accurate history takes a certain amount of time, regardless of your level of experience or ability. in addition, get in the habit of checking the primary data yourself, obtaining hard copies of outside studies, mining the old records for information, re-questioning patients when the story is unclear, and in general being tenacious in your pursuit of clinically relevant material. while this dogged search for answers is not too sexy, it is the cornerstone of good care.
learn from your patients. in particular, those with chronic or unusual diseases will likely know more about their illnesses then you. find out how their diagnosis was made, therapies that have worked or failed, disease progression, reasons for frustration or gratitude with the health care system, etc. realize also that patients and their stories are frequently more interesting then the diseases that inhabit their bodies.
become involved (within reason) in all aspects of patient care. look at the x-ray, examine the sputum, talk with the radiologist, watch the echo being performed. this will allow you to learn more and gain insight into a particular illness/disease state that would not be well conveyed by simply reading the formal report. it will also give you an appreciation for tests and their limitations. caring for patients is not a spectator sport. as an active participant in the health care process (rather then simply a scribe who documents events as they occur) you will not only help deliver better medical care but will also find the process to be more rewarding and enjoyable.
follow up on patients that you care for in the er, are transferred to other services, seen by sub-specialists or discharged from the hospital. this should give you a better sense of the natural history of some disease processes and allow you to confirm (or adjust) your clinical suspicions. this is particularly relevant today as patients are shuttled through the system with great speed, affording us only snap shot views of what may be complex clinical courses.
keep your eyes open for other interesting things that might be going on elsewhere in the hospital/clinic. if there is a patient on another service with an interesting finding, go over and investigate, assuming it doesn't interfere with your other responsibilities and is ok with the patient and their providers. this will give you the opportunity to expand your internal library of what is both normal and abnormal.
pay particular attention when things don't seem to add up. chances are someone (you, the patient, the consultant) is missing something, a clue that the matter needs further investigation. challenge yourself and those around you by continually asking "why... ?"
before deciding that another provider is an "idiot" for adopting what seems an unorthodox or inappropriate clinical approach, assume that it is you that are short some important historical data. give others the benefit of the doubt until you've had an opportunity to fully explore all the relevant information. and in those instances when it becomes apparent that mismanagement has occurred, focus on communication and education rather then derision and condescension.
become comfortable with the phrases, "i don't know" and "i need help."
realize that, ultimately, you are responsible for you. the quality of care that you provide is a direct result of the time and effort that you invest in the process. the distinction between good and bad medicine is generally not a function of oversight by the patient, colleagues, or the legal system. for the most part, it's dependent on your willingness to push and police yourself.
you are not automatically endowed with the historical wisdom of a particular institution merely by walking through its doors. nor does this knowledge necessarily arrive with your white coat, degree or other advanced title. rather, this is something that's learned and earned, often on a daily basis.
every once in a while, push yourself to become an expert in something. first hand knowledge is a powerful tool, one that is available to anyone willing to take the time to read through the primary data. become informed by delving into the original literature pertaining to a particular subject. you may find that the data is robust and the rationale for a clinical approach or treatment well grounded. as frequently, i suspect you'll find instances where the data is rather shaky, and the best path not as clear as guidelines or expert opinion might suggest.
be kind to others and yourself.
have fun! remember why you went into medicine. keep this first and foremost in your mind and periodically readjust your course so that this is always in your sites.

there are weblinks to a number of videos of examinations on these sticky threads:

https://allnurses.com/nursing-student-assistance/health-assessment-resources-145091.html - health assessment resources, techniques, and forms
https://allnurses.com/nursing-student-assistance/any-good-iv-127657.html - any good iv therapy or nursing procedure web sites

then, practice, practice, practice, on every single patient. the last time i was an inpatient i was given a physical assessment by every single nurse that took care of me including every single student. you do what you can and you learn as you go. you get better with each one you do.

shrimpchips, LPN · Jun 18, 2009

The nurses on my floor always do assessments. For the patient that we are assigned to that day, we (the students) are responsible for the assessment and then our nurse will sign off on it. I have never seen my current clinical instructor do a full head-to-toe assessment but that's because she expects us to already know how to do one - and we do. I agree with what some of the others said - you should talk to someone about this. I think you should be doing full assessments all of the time but of course depending on your floor, you might want to do a more focused assessment. For example, if you are on a cardiac floor, you'll have a more focused cardiac assessment. Doing an assessment may also present findings that your nurse might have missed - or there could be changes in your patient's condition. Assess, assess, assess!

I assess LOC and in the meantime I also assessing their vision and hearing without actually doing anything except observing the patient. Are they not looking at you or squinting at you? Chances are they have a visual problem. Do they keep asking "what?" "what did you say?" Chances are they have a hearing problem. I also don't do the penlight thing unless I suspect something. I listen to the lungs (anterior, lateral and posterior) and to the heart sounds. I try to go underneath the gown because then you don't have to deal extraneous noise but sometimes that isn't possible. Listen for bowel sounds and palpate, noting any pain/tenderness, distention or firmness. check the peripheral pulses bilaterally (except for the carotids...don't palpate both at the same time lol) and check for edema in the extremities. I also check for Homan's sign, which is when you straighten the patient's leg and dorsiflex the foot. If the patient c/o sharp shooting pain in the calf, then it is a positive sign. There has been some contraversy as to whether or not it is actually useful but on my floor nurses are required to do it so I include it in my assessment. And always assess the skin! If you're giving your patient a bath, that is an excellent time to observe the skin. Oh, and clubbing of the fingers.

And what about the other students in your clinical? Have they had little experience passing meds and doing other things?

SparkleRN · Jun 20, 2009

Hey everyone - thanks so much for all of your comments and concerns. I was really upset when I wrote that post and I'm really feeling let down by my program. It is an RN program, and it is one year accelerated, so things are going very quickly. I understand that part of it is up to me to jump in and take charge of the situation, but I just don't believe that my instructors thus far have been very patient or compassionate, I think they're tired of being there and on their way out. I'm going to try and slink away to shadow more nurses and ask them to show me how they do thier assessments, however they all have 8 patients and they just seem to be running around all the time and don't want a student dragging them down. I think a lot of other people in my program are just as frustrated, this is not unique to me. Perhaps it is time to try another instructor as well. I think I'm just a little bit confused about what to do in what situation - for example I had a patient that came in with cellulitis in their index finger. Is this a patient that I need to do a full assessment on, bowel sounds and everything? Do I use my own judgement on what to assess or do I always do the full she-bang?? I think I'm going to start by watching some more vids and perhaps making a checklist of things to remember to do when I enter the room so I can refer to it when I stumble. I'm just upset that our instructors keep harping about assessment, but they've never taken the time to make sure we know what we're doing. I want to be a good, competent nurse. I've heard so many horror stories and now I can see where they originate. Anyway, thanks for letting me vent and I'm going to get busy mastering this skill and perhaps take turns practicing with a partner. Wish me luck, cause I need it!

CrufflerJJ, BSN, RN, EMT-P · Jun 20, 2009

Hey everyone - thanks so much for all of your comments and concerns. I was really upset when I wrote that post and I'm really feeling let down by my program. It is an RN program, and it is one year accelerated, so things are going very quickly. I understand that part of it is up to me to jump in and take charge of the situation, but I just don't believe that my instructors thus far have been very patient or compassionate, I think they're tired of being there and on their way out. I'm going to try and slink away to shadow more nurses and ask them to show me how they do thier assessments, however they all have 8 patients and they just seem to be running around all the time and don't want a student dragging them down. I think a lot of other people in my program are just as frustrated, this is not unique to me. Perhaps it is time to try another instructor as well. I think I'm just a little bit confused about what to do in what situation - for example I had a patient that came in with cellulitis in their index finger. Is this a patient that I need to do a full assessment on, bowel sounds and everything? Do I use my own judgement on what to assess or do I always do the full she-bang?? I think I'm going to start by watching some more vids and perhaps making a checklist of things to remember to do when I enter the room so I can refer to it when I stumble. I'm just upset that our instructors keep harping about assessment, but they've never taken the time to make sure we know what we're doing. I want to be a good, competent nurse. I've heard so many horror stories and now I can see where they originate. Anyway, thanks for letting me vent and I'm going to get busy mastering this skill and perhaps take turns practicing with a partner. Wish me luck, cause I need it!

Yo, Dutchess! Sorry to hear that your accel instructors are apparently bozos. Luckily, the ones in my accel program were (for the most part) pretty decent. I think that your feelings of clinical inadequacy are pretty normal - there's TONS of stuff being thrown at you every day in your program, and it's hard to internalize everything. If you were incompetent, you wouldn't be in the program. You can do it, and you WILL do it.

You will need to "drive the bus" in terms of what you get to do. Be somewhat forceful, but not abrasive. Obviously, balance this against the not-so-compassionate nature of your instructors. Lose the "slink away" attitude if possible - you need to aggressively seek out learning opportunities, not wait to be "spoon fed" by your clinical instructors (sorry if this sounds harsh - I'm still working on my touchy-feely sensitivity:D).

At the start of your clinical shifts, get with the floor nurse & ask him/her if you might observe as he/she {screw the PC-speak...your nurse is deemed a female} assesses her other patients. That way, you're not slowing her down too much. You should probably get an "OK" from your clinical instructor before doing this, since it will result in some time spent away from "your" patient. Rather than play "mother may I" with your clinical instructors, take the position of "unless you tell me that I shouldn't, I intend to do blahblahblah." This is called UNODIR (unless otherwise directed), and is sometimes helpful when dealing with indecisive, uncaring twits.

As to the need to assess patients with cellulitis in a finger, YES, do the entire assessment. You need (& want) the practice - treat every patient as a learning opportunity. By doing the head-to-toes assessment (or any other technique) over & over & over & over & over, you WILL be able to do it even when you're tired, sleep deprived, distracted, or whatever. Get it down to the point where you can do it on "autopilot."

morte, LPN, LVN · Jun 20, 2009

Hey everyone - thanks so much for all of your comments and concerns. I was really upset when I wrote that post and I'm really feeling let down by my program. It is an RN program, and it is one year accelerated, so things are going very quickly. I understand that part of it is up to me to jump in and take charge of the situation, but I just don't believe that my instructors thus far have been very patient or compassionate, I think they're tired of being there and on their way out. I'm going to try and slink away to shadow more nurses and ask them to show me how they do thier assessments, however they all have 8 patients and they just seem to be running around all the time and don't want a student dragging them down. I think a lot of other people in my program are just as frustrated, this is not unique to me. Perhaps it is time to try another instructor as well. I think I'm just a little bit confused about what to do in what situation - for example I had a patient that came in with cellulitis in their index finger. Is this a patient that I need to do a full assessment on, bowel sounds and everything? Do I use my own judgement on what to assess or do I always do the full she-bang?? I think I'm going to start by watching some more vids and perhaps making a checklist of things to remember to do when I enter the room so I can refer to it when I stumble. I'm just upset that our instructors keep harping about assessment, but they've never taken the time to make sure we know what we're doing. I want to be a good, competent nurse. I've heard so many horror stories and now I can see where they originate. Anyway, thanks for letting me vent and I'm going to get busy mastering this skill and perhaps take turns practicing with a partner. Wish me luck, cause I need it!

thank you for realizing what you dont know , that you should know......

AH_AH_86 · Jun 22, 2009

You have to jump in there and ask other nurses for help or to show you things. If you feel that your instructor is not teaching you things you should confront her and ask her to show you. It was required that every patient we had in medsurg had a head to toe assessment done and documented the day before clinicals each week.

kgh31386, BSN, MSN, RN · Jun 29, 2009

that program doesn't sound like the best as everyone said. One of our CPE's 2nd semester was to hang a piggyback and start IV's. That's a problem that seems to be common...students not being prepared before graduation. I hope you get to observe more and see more. Don't rely on that "on the job training"...you're paying to be trained now