Patient Assessment

[Mrsladysoul83]

Hello nurses, im a new nurse just starting on a med surge floor, im currently orienting with a preceptor & im always asking questions but never seem to get a CLEAR answer. Ive been a pct for a year so im not new new to the medical field. My question is as far as assessing your patient do you assess them according to their condition/diagnosis & whatever else you feel needs to be looked at or like the whole head to toe assessment they teach in school. I asked my preceptor & she told me whatever i feel is important. Yes definitely ABC's but what else like pupils, the neuro or you can kinda assess all the time lets say you know your patient has good gait because they ambulated to the bathroom while you were in there passing meds. i just dont want to feel like im OVER LOOKING OR UNDER LOOKING ANYTHING. Thanks

[MrsCuoco]

Hello nurses im a new nurse just starting on a med surge floor, im currently orienting with a preceptor & im always asking questions but never seem to get a CLEAR answer. Ive been a pct for a year so im not new new to the medical field. My question is as far as assessing your patient do you assess them according to their condition/diagnosis & whatever else you feel needs to be looked at or like the whole head to toe assessment they teach in school. I asked my preceptor & she told me whatever i feel is important. Yes definitely ABC's but what else like pupils, the neuro or you can kinda assess all the time lets say you know your patient has good gait because they ambulated to the bathroom while you were in there passing meds. i just dont want to feel like im OVER LOOKING OR UNDER LOOKING ANYTHING. Thanks[/quote']

I would encourage you to speak to the unit manager about policy and procedure if you feel your preceptor is giving vague answers. I feel you can never OVER assess, but you do need to know how often and what needs assessed for various types of patients. That said, take the opportunity at each contact with your patient to give a quick look over which can be done with just a sweep of the eyes to be aware of cues and clues that something is wrong. Not every assessment involves poking and prodding and putting your hands on them.

[libran1984, ASN, RN]

VS always paint a great picture in combination with lab values to start watching. The Dx is also, obviously, the prime indicator on what to do in regard to a focused assessment.

Let's take some very "classic" examples of how VS paint a picture: decreased BP and Increased HR might indicate unseen bleeding. Increased HR alone might indicate the very initial signs of dehydration. You know, those very basic concepts.

Look at lab values regularly. If Calcium levels are low monitor for tetany or all of those wonderful indictors like Trousseau's sign. Hyperkalemia, assess cardiac rhythms and heart sounds. Low sodium levels, may cause neuro changes. Check that out. Do you kind of see what I'm getting at?

Then finally, if a pt is admitted to a medsurg floor with PNA, your focused assessment should be based on respiratory. If it is for a SBO, focus on GI. Dysuria, focus on GU.

That, my friend, is how to start prioritizing your new wonderful assessment skills.

PS- grats on being an LPN on a med surg floor! You have a wonderful job and I hope you thrive!!

[TheCommuter, BSN, RN]

I only do full head-to-toe assessments at the time the patient is being newly admitted. Otherwise, I'll do a five-minute focused assessment.

The types of head-to-toe assessments performed in nursing school are too time-consuming to be done on multiple patients every shift. Sweet Brown said it perfectly when she said, "Ain't nobody got time for that!"

[Mrsladysoul83]

Lol @ the commuter, sure don't! Thanks everyone for the replies