head to toe

Ive learned the best way to assess is from the minute you introduce your self or walk into a patients room.

start with introducing yourself and asking them their name

ask them if they know where they are? the date?

pay attention to their speech

once you begin to give AM care do a full skin assessment as you turn them to change or dress them or bring them into a shower, note everything and assess (if they have a rash or skin breakdown?)

capillary refill? blanching on reddened areas? edema? also you can assess their movements/motor skills here also. are they continent/incontinent? if your doing a change you can ascultate their lung sounds while their on their side. Also when they are on their back listen to GI sounds. Vitals can be done as soon as you come in or after their cleaned up. if you need a rectal temp do it while changing.

once you get them up you can do a neuro check with your penlight, and ask them questions/history

those are some basics that have helped me

I haven't started nursing school yet, but I have completed an EMT program, so pt assessments aren't going to be new for me. One big piece of advice is: once you get a rhythm down, do your assessments in the exact same order, every patient, every time. If you jump around, you're bound to forget something.

Practice, practice, practice. When I was going through EMT training (like WahineMakai) I even practiced patient assessments on my dog! I made little mnemonics so I could sing the processes to myself (my ditty for the intestines still cracks me up) when I got nervous or lost my place. Eventually they really do become second nature.