So, I'm having trouble when performing a head to toe assessment on my patients in clinical.
What do you guys typically start with and how long does it take you? I find myself referring back to my notes frequently to make sure I didn't forget to assess something.
I've seen multiple RNs do an assessment, but they're in and out within 5-10 minutes. More often than not, they don't do a complete assessment so I haven't had a good example thus far.
My clinical instructor was an NP and she taught us to get our assessments done in less than 7 minutes. She even timed us to make sure we were getting them done in under 7 minutes.
I have a check off list that I use for quick assessments - just to get the basics (not for new admits). At the beginning it seemed like it took me a long time to even do these basics, but you really do get much faster and more efficient. My quick list is:
T, P, R, BP, AP, O2 SAT, LOC (level of consciousness), Lungs, Bowel Snds, Capillary refill, edema, pedal pulse, skin, and pain
As a PN student, we were taught to do a QPA (Quick Priority Assessment), and uses the ABC, LOC, LOO, IN/OUT, Pain (PQRST), Safety and then proceed to Focus Assessment. The letters stands for the following:-
A - Airway
B - Breathing
C - Circulation
LOC - Level of Consciousness
LOO - Level of Orientation
In - What's going into the body? (IV or O2?) what is the level or setting? is there any infiltration or phlebitis? how is the line from source to patient? any kinks or tension?
Out - NG, chest tubes, catheter, wound dressing, brief/continence pad) What's coming out? Check the color, amount, smell? observe the tubings and ensure there is no kink or tension.
Pain (PQRST) - P-provocative/pallative - what causes it, what makes it worse/better
Q - quality - how does it feel/look/sound ?
R - region - where is the pain located? does it radiates
S - scale - in a scale of 0-5, with 0 as no pain and 5 as severe pain, how do you rate the pain?
T - timing - when did the pain start? is it sudden or gradual? how often the pain comes?
Focused Assessment r/t diagnosis (e.g. if constipated, you can do an abdominal assessment)
Safety - ensure the patient is safe before leaving - bed low, side rails up, breaks on, call bell is within reach
We have to do the above within 10 minutes, and were told that 'expert nurses' do QPA in 5 minutes only.
There is a possibility the nurses are doing a focused assessment. Unless it is a new admit to the unit, this is usually what is done (with some exceptions, including the ICU). For example, you are not going to assess every cranial nerve on a patient who is admitted with a non-neuro problem.
I had an instructor who said, "You're not going to do every assessment on every pt. It makes no more sense to do a full cranial nerve check on a 20 yr old who had an appy, than it does to go into LTC and do a fundal check."
Bubbly26, BSN, RN
307 Posts
My clinical instructor was an NP and she taught us to get our assessments done in less than 7 minutes. She even timed us to make sure we were getting them done in under 7 minutes.