Physical Assessments

[plgunderson]

I have struggled with physical assessment in the clinical setting since I started nursing school a year ago. I always seem to leave something out. I have gone over this and practiced and repeated the process time and again. Does anyone have a "script" that they followed to get it down? I really need to get a handle on this soon! Thanks!

[Esme12, ASN, BSN, RN]

I think you may find what you need here.........

https://allnurses.com/nursing-student-assistance/struggling-thorough-head-781867.html

[KelRN215, BSN, RN]

What are you forgetting? Start at the head and work your way down.

[wish_me_luck, BSN, RN]

Check orientation first as in A and O x 3 (check their arm band and against record then); I do my eyes next even though the lights have to go off--just go head to toe; check for jugular distention or trach deviation; heart and lungs; then abdominal assessment--inspect, auscultate, percussion, palpate and ask about LBM/if they can pass gas; check legs for edema; check pedial pulses and radial pulses; strength--push against hands and squeeze hands and same with feet; check their cap. refill and skin tone/color, temp (use back of hand) and any bruising or ecchymosis, jaundice, etc. and check for any pressure ulcers. Note their urine output if they have a foley and the characteristics of it (color, odor if you have to empty it); make sure their IV line is patent and not occluded, infiltrated, red, etc.; make sure the fluid rate is correct and infusing; and check oxygen rate and make sure if they have O2, they have it on; check amount of NG secretions if they have an NG tube. Ask about pain and if they get up to go to the bathroom, ask them if they need to go while you are in the room as opposed to having to go back in a few minutes. Note if they have SCDs or TED hose; make sure the bed is locked and lowered and again, that they have an arm band; make sure there is only a max of three rails up unless other wise indicated (seizure precautions with the padding) and call light is in reach and room is free of clutter.

I think that's about it.

[knittygrittyRN, MSN, RN]

Honestly in practice most nurses don't do a 'true' head to to assessment. However you do need to know all of it so that you can catch if your patient is decompensating. Everything is more focused based and geared towards what your patient has going on and what could go wrong.

For my health assessment exam I practiced multiple times on my boyfriend and ran through the whole thing. If I missed something I came back and repeated everything. It takes time but doing it is what's going to get you to remember.