patient assessment lab

[gaajr1, RN]

Hello Everyone,

Today we had our first patient assessment labs. It was an experience! I went in with the impression that the instructor would kind of demonstrate once before we actually do things. But that was not the case, we were thrown in water and asked to swim.

Our instructor gave us the assessment sheets in which we had right from physical appearence to all the peripheral pulses, bp, resp rate etc. In the end we had to write an analysis of all our findings. It made it worse as I couldn't find the pulse on my partner. Later I found that even our instructor could not!! Well...

The problem I had most was in using the right words when writing the analysis ie using the accepted language of the medical world. It is all the more imp because we are graded at the end of the lab. I plan to try checking pulses and bp on my family and anyone willing to be my guinea pig.

This is all new to me and wondering if anyone can suggest how to go about with it. I would really appreciate if you have any suggestions for I am new to this. Hopefully before I start the nursing program in Fall, I will feel more confident. Thanks a lot!

[catherine_cardella]

I had my assessment lab last semester and our instructor wasn't terrible but she certainly wasn't the best. She was OK with demonstrating assessment techniques but the students were completely lost as far as documenting went . I was at somewhat of an advantage because I work as a student assistant in a cancer research office where the research assistants are excellent at documenting. So, I was exposed to many of the shorthand abbreviations and such. But I still had no idea what some things meant like 40 y.o. F WGWD NAD. Maybe your class could ask the instructor for examples on how to document a full assessment. Or search online for abbreviations examples :typing. That might be your best bet. Even if you don't know what abbreviations and shorthands to write, just keep your observations clear and super duper concise.

We had partners to practice assessments on. If you're not sure how to do something, be sure to ask. And be sure to know what each test looks for and it might be good to know some examples of abnormal results. At the end of the semester, we had to perform a complete assessment on our partners in front of the instructor and we would be given a grade for it. It wasn't as hard as I thought it would be, but I was practicing weeks ahead of time because I was so nervous that I had a nightmare about it.

Things might not make any sense to you now, but you'll get the hang of it.

[gaajr1, RN]

Thanks pynkladie! Actually my instructor seems a very nice person, but just the expectation of us knowing things right from day one, is a bit daunting. Also, it is not so much about the abbreviations, but the whole analysis writing. The way you summarize all the data you have, using appropriate language.

As you suggested I will go online and check and also ask my instructor for guidance. We too work as partners but everyone is struggling at different levels. We too have a final head to toe assessment at the end of semester. But as you said, hopefully I will get a hang of it, SOON!

[Daytonite, BSN, RN]

there is a sticky on assessment with lots of helpful weblinks:

• https://allnurses.com/forums/f205/health-assessment-resources-techniques-forms-145091.html - health assessment resources, techniques, and forms (in nursing student assistance forum)

one site, that i know of (http://medicine.ucsd.edu/clinicalmed/introduction.htm) has a link on it called "write ups" where you can see examples of how to write up the results of your examination of various parts of the body examination. if you have a textbook you are working from, check the appendix to see if there are examples of write ups there. the textbook of physical examination that i have has a whole chapter on documenting the findings of a physical examination.

[gaajr1, RN]

Thanks a lot Daytonite. I will definetly check the link you sent. Actually I did check my textbook, but it doesn't have the write ups. Writing it right is so imp that I want to find all resources possible. Thanks as always.

[mariasmomma]

Okay, I know this is an old thread but it is the only search hit I am getting that is close to what I am looking for. What does the abbreviation WGWD and NAD stand for??? I can't find it anywhere in my books and my instructor put it in the notes but did not explain it. Help please and thank you.

[dittosaur-bandaid]

I've never heard of WGWD, maybe someone else has. What part of the assessment do you see that abbreviation? Maybe that can clue you in. WG generally can be talking about weight...also NAD can mean "nothing abnormal detected", but again it depends on the context.

You can try searching for it from a medical abbreviations site like medilexicon.com, but if all else fails I say deal with the temporary embarrassment of having to ask your instructor to clarify...at least then you'll know for sure and never need to ask about it again! :)

[mariasmomma]

Thanks bandaid. It is so strange because the second poster in this thread also had an instructor use that abbreviation. It is not in medilexicon, but thanks for the site, I'm sure I'll be using it a lot. I'll post the answer when I find out. Probably something super obvious...