Help with wordings?

[blueLearning]

(freshman nursing student here)

okay so my instructor made a comment about my assessment that i should make it sound more like a nurse working in the medical field but did not point out which and how.

here is a part of my assessments. Please help because i have no idea what she meant, these all came from the book and some from other forums. please help me. i would provide my entire assessment paper but the copy-paste function is being difficult.

Eyes (general assessment and note any deficits)o

Eye brows symmetrical, outer cantus in line with upper pinna of ear bilaterally;pupils equal round reactive to light and accommodation. No deficits noted inperforming the 6 cardinal gazes. Client stated that she wears glasses regularly.

Ears (general assessment and note any deficits)o

Upper pinna of both ear is in line with outer cantus of the eyes. No signs ofredness or swelling. No drainage. Hard of hearing, wears behind-the-ear type hearing aids on both ear. No pain upon palpation.

Nose, Mouth, Throat

Nose is located midline, no discoloration, no discharges. On 2L of oxygen via nasal cannula, with nasal flaring upon exertion. Pinkish with some dryness of lips, buccal mucosa is moist and pinkish in color, uvula is located midline, able to move tongue in all directions, wears dentures, no complains of pain or discomfort when masticating, with minimal alterations to taste, No signs of dysphagia.

[windsurfer8, BSN, RN]

If you are confused with what the instructor assigned clarify this with them. It is no different than working with a doctor and asking for more clarification for an order they write. School isn't always about the "answer". It is learning how to get the answer in the proper way. Meaning if I was a patient I would not like them choosing my care from random people on the internet.

[blueLearning]

the thing is i did came up to her about this, told me didnt know how else she could tell me how, Ive looked at other people's work as well. Ive read my primary nurses' chartings during clinicals. so im lost, talking to her just made me feel like i knew nothing.

[mrsboots87]

What she probably means is that for complains of you can use c/o, dont say "pinkish", use pink, red, purple, or if its pinkish red then use pink/red. Use PERRLA for pupil reaction. No signs of redness or swelling and no drainage can be written as no s/sx of infection or drainage. Unless you are doing a neuro check and properly trained, you do not need to note the cardinal gazes. Wears glasses is sufficient. I don't really care about eyebrow level unless there are signs of stroke or facial drooping, trouble opening the eyes, facial swelling, etc. if none of that, then no need to write about the eyebrows. (but ask you instructor as they may want it as a learning tool.)

Try to use some of the appropriate abbreviations. No one wants to read a paragrapgh that can be condensed to a few line if they don't have to. I will give you an example of how I would write this, even though there is other info I would have included in my assessment as well.

Eyes (general assessment and note any deficits)o

PERRLA. Wears glasses. (was there redness or irritation, swelling of the eyes, drainage, cataracts, that is what I would want to know and noted) The other stuff doesnt need to be there unless you instructor specifically asks for it or there is a reason for assessing it.

Ears (general assessment and note any deficits)o

Ears midline of head bilaterally. No redness, swelling, or drainage. Uses hearing aids bilaterally. No c/o pain or discomfort on palpation.

Nose, Mouth, Throat

Nose is located midline without deviation. Nasal flaring noted. (insert O2 sats) on 2L per NC. Oral cavity pink and moist with dry lips. Uses dentures (are they full dentures, does the patient have any teeth?). No c/o pain or discomfort when masticating. No dysphagia noted.

Again, this is not exactly how I would assess and chart, but it does fix what you did asses and chart.

Look at assessing and charting as what you need to know and what the next nurse should know. Ask yourself why you are assessing something.

Example, why did you assess the eyebrows? Was the resident there for hx of stroke? Did they have facial drooping you didnt note? Did they have a facial trauma? Charting about eyebrows would make me think there was an abnormal assessment in the past and knowing their placement on the face is now important. If not, then it is a waste of time.

Why did you check the cardinal gazes? This is a neuro check and not routinely done unless there is a neurological need to do it. Again, you do not need to assess and chart this just because.

Why do I care about the placement of the ears? Is there a facial trauma? Did the patient have a misshapen head as an infant? P.S. did you assess the trachea in this area. We do need to know if the trachea is midline or not. I would assume you have not learned why yet or you would have assessed it, but as good practice until you know why, always assess if the trachea is midline or deviated to the left or right.

I could go on, but my point is not to nit pick. You are learning and this is a good start, you just need some tweaking and some redirection.

[blueLearning]

thank you. i wish there's actually a lecture about how to state these things. we've had different instructors and they do things different which i understand why. its just difficult having different people grade you when there's no consistency on each expects/wants.

[Kuriin, BSN, RN]

Ermm...I'm going to have to side with the student on this one. Assessments look fine. OP may not be using abbreviations of someone in the medical field, but that doesn't matter. As long as you have clear and concise information. If the teacher really wants to teach her, she/he should provide the student some information.