Assessment

[Yalith]

Can someone please explain to me what is expected for an initial assessment when you are at clinical (or nursing) at the hospital?

My first clinical where we were supposed to learn assessment, the instructor didn't seem to know what he was doing, and he didn't teach us anything much (except he taught me how to make a bed once). Mostly we just hang around the nursing station and studied the patients charts and practiced blood pressures. It wasn't until near the end of the semester that we had a substitute and she was shocked at how little we knew. She asked me to do my assessment and I didn't understand what she was even talking about. Then I realized she must want me to do assessment (so that's why we were taking that assessment course! duh) so that I could fill out the flow sheet. SO I figured it out from there.

My next clinical I had an awsome instructor but she was busy finding time to teach us to give meds and stuff so there really wasn't time for her to teach me assessment which I was already supposed to know. So I did my best to come up with my little assessment plan, which works to fill out the flow sheet and get information, but I think I'm disorganized.

Over the summer I got a job as a nursing attendant. I was able to learn the stuff an aide does from that job. I wish I had known how to do everything before I started working there though. Guess I could've read my textbook more...

And one question I still have is, are we supposed to be doing the COMPLETE head-to-toe examination when we are at clinical? Or is it just a shorter version of that? I am assuming it is a shortened, focused, assessment. Is this correct? Also, do we do the health history and general survey too? Is there anything else that goes along with it? (Some of this I think I might know but I'm craving clarity!)

And any advice for doing assessment you have for me? What's the most important thing that you would like a student to know about assessment?

[J9G2008]

In our clinicals, we are expected to do the complete cephalocaudal assessment, and complete an assessment guide based on that with any abnormals highlighted (7 pages). The assessment guide also includes the details from their history that we interviewed them for. We use the chart data as well, and include vitals. Then we use that to produce a care plan. We also, now that we are passing meds, are responsible for three drug sheets.

If I were you, I would get out your information on assessment, and get into the practice lab to learn it, and then do it on some real patients. It not only helps you know what is normal/abnormal, it gets you into the habit of reporting this info in the medical way. "Umbilicus is midline and sunken" vs. "belly button in the middle. It's an innie." You know.

I don't really think assessment goes away in nursing.

[PsychNurseWannaBe, BSN, RN]

Your questions are best answered by your individual instructor. Some instructors want a head to toe, but as you progress in the program, they might allow for a focused assessment instead. Try to get comfortable with doing head to toe assessments, since you will use this skill in work. For example, we do head to toe upon admission but than a focused one for whatever is wrong with the patient.

Your head to toe will or should include a comprehensive assessment, meaning that you address your patient holistically. Normally along Marjory Gordons Health Patterns.