Assessments - need help with terminology

[nrstdwalden]

I'm currently in an LPN - RN program. As an LPN, I currently work in an immediate care type setting and we focus on the problem at hand, so I don't do head to toe assessments everyday. Now being back in the hospital setting at clinicals, I have the ability to complete my assessment but when its time to put it on paper I can't seem to come up with the terminology to describe things. Does anyone know of a book, website, or anything that would be helpful. Thanks.

[NursingIs4CoolPeople]

i think the standard is physical examination and health assessment by jarvis. there's a pocket edition which is great for carrying around during clinical.

[picurn10]

I saw barnes and noble has one in the "incredibly easy" series called "assessments made incredibly easy" and "charting made incredibly easy" We were given a little laminated card when we started our assessments that I still check from time to time to make sure I'm doing it right, and using the right termninology. You'll get the hang of it! Congrats, I'm about to graduated from LPN in June and will be starting my bridge to RN in August, I can't wait!!!!

[shrimpchips, LPN]

i think the standard is physical examination and health assessment by jarvis. there's a pocket edition which is great for carrying around during clinical.

I second this! I don't have the pocket edition because I didn't know about it when the I bought the actual textbook, but I wish I did! The pocket edition is pretty much the textbook in pocket form. The textbook itself is an excellent resource and it's easy to read and understand.

As for describing things...just chart and describe exactly what you see! Or come have the nurse you are working with or your clinical instructor look at what you need to chart and have them help out (such as having them look at a wound or poop or something)

[nrstdwalden]

Thank you everyone, I'm gonna check out both!