First day of clinical...physical assessment issues.

[aWiiPeanut, ADN]

Hello! Today was my first day of clinical and we basically followed a nurse around for 6 hours and assisted her with various things...ausculatating before/after meds, etc. So we also have to complete an 11 page 'Assessment' on one patient each clinical day. We can get some of this information from the chart; however, the huge portion of this is the physical assessment. Here comes my question... is there a way to group certain parts of the assessment together to make it more efficient? I feel like there is 'dead air' because even though I read over the paperwork several times before clinical, there was a lot of time spent doing one thing and then asking questions and taking notes, then doing one more thing...etc, etc. I hope this makes sense.

[Miss.LeoRN]

We had this massive paper chart assessment to fill out for our clinical too. A lot of it was repeat info. I basically broke it all down and made my own brain sheet/assessment tool. Clinical is the time to start perfecting your assessment skills. Simplest way is head to toe, so that's what I did. I made a brain sheet of a head to toe assessment in the order of how I want to do it, what questions I need to ask, and carried it with and followed along. I memorized it in no time and to this day still follow it's basic outline despite making various revisions asking the way.

[emmjayy, BSN, RN]

Organize your assessment from head to toe. Think of every possible thing you could assess for each body area and then write it all down in painstaking detail. For example, starting at the head.... are they awake (or easily arousable) and alert/oriented to person, place, and time? Are their pupils equal/round/reactive to light? Sclera white or yellow/red/edematous? Any vision problems? Do they have an NG tube? Is it causing irritation/skin breakdown on their nose? Can they hear? Do they use hearing aids? If they're wearing a nasal cannula, is it causing irritation/pressure injury behind their ears? Moving on, is there face symmetrical? Tongue midline? Lips/tongue/mucous membranes moist? Inflamed? Dry/cracked/breaking down? Coated/painful? Did you provide oral care? Do they have all their teeth or do they wear dentures? Able to handle secretions? Any complaints of pain in their throat or difficulty swallowing?

And then just move down, making note of literally everything you possibly can make a note of. Think about the reason the patient is there and focus on that body system. If they're in with a COPD exacerbation, do a great lung assessment, note the supplemental oxygen they're receiving and how they're receiving it (there's a big difference between a COPD'er who's doing okay on 4L NC and one who needs BiPap). Note their chest - are they barrel chested? Using accessory muscles to breathe? Doing pursed-lip breathing? Respiratory posturing? How's their work of breathing? O2 sat? How's their mental status throughout the day? How do their lungs sound before a treatment vs. after a treatment?

If you get real nit-picky and down into the details of each body system, you should be able to fill your space. Will it be dreadful and annoying and time-consuming? YEP. But you should definitely be able to do it :)

[Jstimmm]

We have to do this too. Every clinical. I know it sounds silly, but I am a sing songy type of person and have to group things together with either word association or songs/rhymes. I group it in the order of HEAD, Shoulders, knees and toes- and when I'm doing the head or neuro/PEERLA, I do it in the order of hair, and then eyes and ears and mouth and nose- like the song! lol it makes things a bit more interesting and I don't forget anything. When I do shoulders, I make that the heart and lung sounds..

[TheDudeWithTheBigDog, ADN, RN]

I know as a student my advice doesn't stand up to an experienced RNs, but for me, I just go head to toe. For the head, I go one part of the head at a time. So I start with neuro, then scalp, then eyes, then ears, then mouth, then nose and sinuses, then neck, then lymph, then pulses. Then I move onto the thorax/CV. Then abdomen. Then I'll do the upper body ROM and pulses. Then the lower body ROM and pulses. Then finally, I'll have them stand up and I'll do their back and gait. Before I start each new section of body, I assess the skin in that section. If I find anything abnormal along the way, then I'll go a little more focused on it

As you're doing it, follow emmjay's advice. And if you see it, whether it's normal or not, note it.

For your questions... I'm still pretty bad at that. But how I do it: As you go, ask about any problems with that body part or joint, because every body part can have problems.