What is included in a legit assessment?

[SkiMama]

B/C if the way my docs/nurses in the past have performed assessments is any indication of thoroughness, I could disregard the bulk of my assessment book.

I start my assessment course in June, though I've already started reading, preparing for class. I am wondering how in depth we will be going into pt assessment in class/clinicals... b/c from the looks of my book, I could spend an entire day just on assessing the pt!!

The questions, the examination of eyes, ears, skin (etc...) 800 different ways. We cannot seriously be expected to include everything in assessment book each and every assessment!!

Someone reassure me that it won't take 12 hours to perform a correct assessment... please?

[BacktotheBeach, ADN, BSN, RN]

In my nursing school, we learned a head to toe assessment and it differs vastly from the textbook. It is the first thing we do on all patients assignments at the start of the day and it takes about 10 minutes and includes time for VS. There are lots of examples on YouTube and that is a great place to get an idea!

[SkiMama]

Thanks for the tip! I just could not believe that we would have to do everything that the book includes at all times, yikes!

[anonymousstudent]

You will learn each system that way, down to the minutia.

You won't really do an assessment like that though. You can be thorough and fast, and get the data you need.

Vital signs, including pain!

Breath sounds.

Heart sounds.

Bowels sounds. THEN palpate

Pulses.

Cap refill (maybe)

Edema?

Skin - integrity of the IV site, status of incision, etc. Color, temperature, MM's moist or not?

Neuro - are they oriented, confused, etc... any numbness?

How are they doing with their current situation emotionally? Has family been in? Do they have any concerns?

Call light within reach? Bed down? Walker/crutches/whatever close by? Bed rails up? Bed alarm set?

Then you add on anything that's pertinent to that specific patient and their care. If they had a head injury or spinal surgery obviously your neuro stuff is going to be more complicated. If they just had a baby you are checking fundus and peri. You need to check drains, tubes, correct IV flow rate, dressings, etc as needed.

Just go from top to bottom or whatever makes sense to you. Just find a way to make it make sense and you won't miss anything and you'll be able to go super fast. :)

[OB-nurse2013, BSN, RN]

I just finished my assessment class and although u learn so much detail its because depending on what area you are working or have your clinical at you may do a more thorogh assessment of that system so in our assessment class we learned how to do a more involved ass. of each area but our head to toe did not include everything just key points which took us about 15 minutes to do :)

[JBudd, MSN]

Anonymous and Patho hit it for you.

All the detailed stuff is when that area is your patient's specific problem. You can do a head-to-toe reassessment in about 5 minutes (not including VS): Look at LOC, body position, facial mobility and symmetry (all can be done while introducing yourself). Shaking hands during introduction gives you some muscle strength and mobility, as well as how well they hear, speak and follow commands, and skin temp (w/d, clammy, etc.)

Have them sit up, listen to lungs, heart and belly (more LOC, ability to follow command and mobility). Feel the ankles for edema, check the IV site, dressing/wound/cast etc.

One reason you don't see docs and experienced nurses doing a whole lot of it, is we have learned to do a lot of assessment unobtrusively, just while talking or doing other tasks. Assessment becomes automatic, and nonstop.

The complete and total head to toe with otoscope, reflexes, cranial nerve checks, PERRLA etc. only needs to be done occasionaly, such as on admission or when you are suspecting a significant change. My student perform theirs in 20 minutes for their final exam.

It is a huge amount of information, but it does all come together and make sense with time and practice! Good luck

[anonymousstudent]

Oh yeah, what JBudd said about gathering data from the minute you hit the door is key. A lot of students in my clinicals don't get that and they struggle. Just pay attention. I was working with a student in the nursery a few quarters ago and she took the baby's HR, listened to lungs and bowels. Then she starts documenting and tells me that she needs to go back because she didn't get the quality of his breathing. WHAT? She just spent 5 minutes looking at him breathe. Seriously, pay attention. I know it's easier for some than others, but you can grab a lot of data without even knowing it or trying very hard.

[SkiMama]

Thanks for the replies! I read a few articles and watched a video on youtube today and it all makes sense now. I understand why it's important to know how to go much more in depth on each system depending on pt needs - and am so glad we don't have to go that in depth each time!

Clearly I have a lot to learn and so excited to get into it soon!

[Despareux]

In retrospect, I made my assessment class far more difficult than it had to be; because now, I can whip out an assessment in about 5-10 minutes. But it is good to know how to assess areas per patient complaint or something you may suspect on your own.

When I was taking my assessment class, I was sort of ticked that we were taking this in our very first quarter because I felt it was geared toward more experienced nursing education--like closer to graduation. Now I understand why we had to take the class when we did.

And now that I know how to do assessments, I find myself always performing observational assessments--especially on little kids, since pediatrics is the field that interests me most.

It will all come together very soon. :)