Head-to-Toe Assessment Question

Daytonite, BSN, RN · Oct 7, 2006

when i was very new at it, i took the attitude that i was playacting at it. that, i hope, put the patient at ease. with experience, you can drop that false sense of security because it will be replaced with the real thing. there have been a number of times over the years when a new procedure comes along that i have had to adopt this kind of false confidence in front of the patient. i recall when we had to do our first dressing change of a patient receiving tpn (total parenteral nutrition). now, that may seen ancient to some of the newer forum members, but at the time it was a big thing. i clearly recall how scared i and another rn were as we stood together getting this patient's sterile dressing changed, trying not to contaminate our sterile field, and trying to appear as if we knew what the h-e-double hockey sticks we knew what we were doing! the same applies for working around really smelly body discharges, hearing shocking things from patients mouths, and other nasty and unexpected things you are likely to run across. mask of false confidence. my nursing instructors called it, the professional face. it will get you through just about anything.

S.T.A.C.E.Y, LPN · Oct 8, 2006

I have a little sheet I take with me to clinicals that has the important details of my patient on it, along with a rough schedule of my day (with meds), and an assessment guide. That way when I do my assessment, I don't need to hum-n-haw and try to remember what comes next, just check things off, and write abnormalities. When you haven't committed the whole asessment process to memory or have it become second nature, that little guide helps me feel like I know exactly what I'm doing.

I had one instructor who also told us to watch our language, cause that can easily change our perception of ourselves and the patients perception of you. Instead of asking to listen to someone's abdomen, tell them that you need to listen to their abdomen. Our instructor said it helps the patient feel that what you are doing is routine, rather than an exception that you need to ask about.

XXmordridXX · Nov 29, 2006

does any one have any personal suggestions on making an easy sheet to go by for assessments?

mysterious_one, ASN, RN · Nov 29, 2006

I use an assessment guide that our school provided , I am trying to upload it , I am not sure if this works, if not PM me

Assessment guide.pdf

S.T.A.C.E.Y, LPN · Nov 29, 2006

This is what I use in Clinical for Medicine. If I have two patients, I'll just print it twice back to back, and highlight the headings on one side so I don't mix them up.

The assessment stuff follows the hospital's guide for documentation. We chart by exception, so all of the assessment points listed are considered 'within normal limits'. When I sign my name in the chart, its saying that all of that stuff is ok. Anything abnormal I have to document.

S.T.A.C.E.Y, LPN · Nov 29, 2006

Sorry, had to figure out how to attach the file. [ATTACH]Clinical Assessment & Plan[/ATTACH]

Assessment.doc

jemommyRN · Nov 29, 2006

Thank you guys so much for the sheets. I'm sure this will help in clinicals as we are assessing our patients.

kimber1985 · Nov 29, 2006

I am a student. In terms of touching a stranger, I try to introduce myself and chat with the patient for a bit, then come back for a physical assessment. When I come back, I don't have to AAO them, I have already done that.

Just act like it's no big deal. Don't feel like you are asking them for a favor. You are the one doing them a favor. If you hear or see something funny, address it, get your instructor.

You are learning, so focus on what is wrong with your patient so you can learn about lung sound, irregular heart beats, etc. Ask to watch your nurse do an assessment, so you can see how others do it. If you forget something just go back in and do what you missed. Good Luck.