Physical Assessment and Care plans

[blessed2bfree]

Can you do a good careplan without taking a physical assessment class? At our school, which is an ADN program, we don't take a physical assessment class until third semester. We done careplans in second semester and used data from the patient's chart and vital signs that we done. I just always felt like in order to do a careplan the correct way, we needed to do the assessing. What's your thoughts?

[Mike R, ADN, BSN, RN]

Shoot, our program doesn't even offer physical assessment classes. They just drill and drill into us how to do good physical assessments from day 1. Each clinical we have 3 patients (first semester) and we always need to turn in a completed physical assessment form for each patient with every pain staking detail.

But you're absolutely right. It's hard to do a good care plan with out a thorough physical assessment. How do you know how to treat if you don't even know what you're treating? So every clinical, after obtaining report from the night shift, first thing we do is our physical assessments.

[mg08]

I actually think its really possible, in my BSN program, we did have a physical assessment class before we started doing careplans, but honestly i havent used any information from my assessments other than vitals and for my AEB in the NDx to do my careplans, and they all turn out really well :)

[ImThatGuy, BSN, RN]

The associate degree seekers don't get health assessment courses. Us BSN geeks do. That said, we're both choking down careplans. It's not hard.

[Heart for Nursing]

Actually some ADN programs DO have physical assessment. I am in my first semester of an ADN program and while we are at clinical, you better believe we do physical assessments along with basic care. Care plans or plan of care are long and tiring but you do what you have to do. I believe you can do a good care plan without doing a physical assessment but its just hard because you didn't do it yourself or actually see how your patient improves or sadly, decline.

Every school is different. But all are hard.

[Becca Thomas, SN]

Hi my name is Becca Thomas and I just recently started my two year nursing program (RN program) in Centralia, Washington. And I am supposed to make to posts on a message blog and I saw that you posted on physical assessments. I was wondering if any one would be willing to explain to me how you do your physical assessments on clients and why you do what you do? I would greatly appreciate it so much! I just want to see the variety in doing good, thorough assessments.

Thanks so much!

[Nurse Kyles, BSN, RN]

i'm surprised you don't have a physical assessment class until third semester. i attend an associate degree program. we had a first semester class "nursing skills" in which we learned physical assessment, injection technique, med administration, catheter insertion, ostomy care, g tube med administration, wound care and others that are slipping my mind right now. also we learned about basic diseases and abnormal conditions. first semester clinicals didn't have us doing hardly any cares at all.. we focused on the rn role. care planning, assessments, skills, and application of critical thinking were the focus.

for becca head to toe clinical guide:

1 identify patient

while holding hands do cap refill, note temp, check condition of nails & radial pulses

assess motor ability of upper extremities (grip strength etc), sensation of ue

2. vitals including pain (medicate if necessary)

3. chief complaint: pqrstu: provocative, palliative, q:quality,quantity, r: region & radiates,

s:severity, t: timing, u: understanding of patient's perception

4. focused assessment based on complaint

5. head, neck, lymph nodes, eyes, ear, throat

ask about any problems with vision, hearing, sore throat etc

inspect for abnomalities: note motor ability of head, condition of hair

use pen light to assess eyes & throat: if infection present or suspected palpate lymph

nodes

6. anterior chest

ask about problems breathing, chest pain etc

inspect for abnormalities: note: ap

palpate for abnormalities

lung sounds (modify per patient condition-concentrate on bases)

heart sounds (apetm- diaphragm and bell)

apical pulse at mitral area for one minute

5 gi

ask about last bowel movement, urine output, etc

inspect for abnormalities

auscultate bowel sounds in all four quadrants

light palpate: do not palpate if there is an abdominal incision, mass or any other

abnormalities noted

6 lower extremities

check edema, temp bilaterally, note skin/nail condition

note motor abilities (plantar/dorsi flexion, ability to move le & strength)

check for pedal pulses bilaterally (dorsalis pedis & posterior tibialis)

check for capillary refill bilaterally , sensation if lower extremities affected

7 posterior side

inspect posterior skin (focus on areas of pressure)

palpate posterior chest for abnormalities

lung sounds, bases first + sides

8 other assessments:

mood, psychosocial status

check iv site for redness, pain, swelling + iv pump for rate, fluids, etc

wound dressing assessment if appropriate

family/social support

safety issues

inspect perineal area during bathing/brief change

[jnick31]

I am in an ADN program and our physical assessments build upon itself each semester. Sem. 1 is alert or not/PERRL/ect. Sem. 2 is LOC/PERRLA/ect. Sem. 3 is GCS/PERRLA (including pupil dilation in mm)/ect. and so on. I think it's possible to do a care plan without doing your own physical assessment but it will be better if YOU do it. When you do them based on charts you are just using someone else's assessment data which may or may not be current. It can still be done... and will likely still be a good care plan but may not be based on the most current situation. i.e. those crackles may have cleared up 2 1/2 days ago but no one has bothered to chart that.

[Becca Thomas, SN]

Thank you so much for making that great flow list of all the steps I should do! It was extremely helpful and I appreciate seeing new ways of doing a complete physical assessment! Thank you, thank you, thank you!!!

[msjellybean]

The associate degree seekers don't get health assessment courses. Us BSN geeks do. That said, we're both choking down careplans. It's not hard.

I had an assessment course & I went through an associates program.