Help with Assessment

UM Review RN, ASN, RN · Aug 19, 2008

Somewhere around here are some links to do assessments that will help you. Meantime, definitely listen to the posterior lung fields! Always! Breathing problems can be an emergency very quickly and this is one area you need to be an expert in.

Also, listening to the heart is important. There are certain conditions which can cause different sounds, so it'll clue you in to your patient's needs better if you can identify them.

Lung sounds: http://www.wilkes.med.ucla.edu/lungintro.htm (There are tabs to listen to heart sounds here also.)

http://www.rale.ca/

Always remember: The more you know about the pathology of a disease or condition, the better you can help your patient. :nurse:

Music in My Heart · Aug 19, 2008

i am starting my 3rd semester of ns in 1 week and am having some anxiety over my upcoming clinical. my instructor has a reputation for being a difficult instructor. i have heard that she has failed students for not correctly identifying abnormal heart and lung sounds. therefore my main concern is over performing a thorough assessment. i have been reading the archives and found lots of great info. i am currently a nap and feel comfortable doing an assessment but i don't know if it will be "thorough enough" for my instructor. this is what i am doing now with my patients:
introduce myself and ask them their name and if they know where they are and why they are here.
explain that i am going to do an assessment
you should ask their permission before doing anything to a patient.
[*]ask them how they feel. how did they sleep? feeling better or worse or about the same?
[*]listen to their heart and lungs (i only listen from the front and sides though, maybe i should listen to the lungs from the back?)
you should definitely listen from the back because the lower lobes are predominantly represented there.
also, listen on the skin, not through clothes
[*]listen for bowel sounds and palpate abdomen, ask if it hurts
[*]ask when is the last time they urinated and had bm
ease of pooping and peeing, normal for them?, color, consistency, and quantity
ask about their appetite
[*]check pulses (radial and pedal) and capillary refill
[*]check iv site
[*]assess skin and check for edema (i mainly just look at legs and arms)
don't neglect the backs and hips -- all bony prominences.
[*]ask them if they are having any pain and have them rate it, ask what makes it better or worse
[*]check dressings (if present)
[*]check drains and cath bags
[*]
my question (finally) is do you think this will be a satisfactory assessment for my instructor? or do you think i should add anything?
thanks for the input!!

a few things popped into my mind as i read your list.

good luck with your new instructor. i'm starting 3rd semester clinicals with a new instructor, too, and she likewise has an intimidating reputation.

lemonaidangel · Aug 19, 2008

At my school we use a head-to-toe approach.

1) We introduce ourselves to the client and explain what we are going to do.

2)Start with the head

a)look at their scalp for any lesions

b)note facial symmetry

c)examine their eyes, use the penlight to look for PERRLA

d)look at the setting of their ears noting symmetry, scars and lesions. Palpate for any tenderness. Test hearing by whispering a two-syllable word in one ear at a time and have them repeat it to you.

e)look at their nose, noting anything out of the ordinary, and patency. Be especially aware of dry skin and skin break down if they are on oxygen

f)use penlight and look inside mouth, paying close attention to their tonsils, fillings/broken teeth, and be sure to look under their tongue because that is the most common site for cancerous sores in the mouth

3)Neck

a)Test ROM of the neck and shoulders

b)auscultate for bruits

c)feel the lymph nodes for swelling

d)pulses are always important

a)palpate the trachea for any deviation from the center

4)Chest

a)Obsverve symmetry of breaths, if they have to use any accessory muscles to breathe, look for any unusual scars on their back and chest, note configuration of the chest (is it barrel shaped, etc)

b)listen to breath sounds (front and back! The majority of the lower lobes you can only hear from the back!)

c)Listen to heart sounds in all five locations (apical, erbs point, etc.)

d)feel the apical impulse --not uncommon to be unable to palpate this is 50% of the population

e)check skin turgor by pinching their skin by the clavicle

5)abdomen

a)observe shape, size, lesions (including stretch marks), and anything out of the ordinary. Note if you can see their pulse near their aorta because that could be indicative of an aneurysm

b)Listen for bowel sounds in all 4 quadrants

c)palpate for any tenderness or lumps

d)If you are required to take a femoral pulse, do so at this point

6)arms and hands

a)have them stetch out their arms and note symmetry, scars, lesions

b)ROM

c)palpate their radial pulses

d)Have them grasp your hands tightly and note strength, and have them push your hands away against resistance

e)capillary refill

7) Legs and feet

a)ROM!

b)Scars and lesions

c)Popliteal pulses

d)foot pulses

e)check for edema

f)toenail condition

g)capillary refill

8) If they are able to stand, at this point you want to test their balance and their gait by having them walk a few steps.

It seems like a whole lot, but it's really not. After enough practice it only takes about 10 minutes, and usually you can do a many of your assessments at the same time. There are a lot of short cuts. For example, while you are listening to lung sounds you can check out the condition of their skin without them knowing it. Or just by having a normal conversation with them you can tell if their face is symmetric, note obvious facial scars like birthmarks/acne/stitches, assess mental status, hearing abilities, if they get short of breath or have to use their accessory muscles while talking, etc. All this goes on in a matter of seconds. Or you can assess their gait by watching them when they get up to go to the bathroom. And so it goes. Easy as pie.

You must constantly assess skin. Every time you walk in their room pay special attention to their IV site. And if they have bandages, at least once a shift check the wound for signs of infection/healing. If they are completely bedridden and you have to turn them every 2 hours, make sure you assess for skin breakdown around all their bony areas. Bedsores are so easy to prevent, but so hard to heal!

Bortaz, MSN, RN · Aug 21, 2008

Before you use the penlight to check PERRLA, shouldn't you ask them if they've had instances of glaucoma or other eye trauma?

One of the best assessment tools you can ever use is your mouth. Talk to the patient.

lemonaidangel · Aug 21, 2008

Before you use the penlight to check PERRLA, shouldn't you ask them if they've had instances of glaucoma or other eye trauma?
One of the best assessment tools you can ever use is your mouth. Talk to the patient.

Yes, that's true. Good point, and thank you for bringing that up. I was merely reviewing the head-to-toe process. I usually do my interviewing before my complete assessment in clinical. It tends to work out better for me that way.

:)