Right in the first semester of nursing school, in nursing fundamentals, you start learning the art of assessing a patient, and as the courses progress, so does your assessment skills. There is a reason patient head-to-toe assessment is one of the first things taught in nursing school, it is one of the most crucial and vital aspects of nursing. Everyday, multiple times per day, on every patient, you must continue using this skill. I have seen nurses finisdocumenting a complete assessment without even actually checking the patient and chart heart and lung assessment without taking the stethoscope from around their necks. Do not lose your fundamental nursing skills, perform a thorough assessment on your patient at the beginning of your shift to obtain a baseline, and if any changes happen throughout your shift you will be aware and able to recognize.
A study conducted in a 800 bed hospital in Sarasota, FL, assessed the clinical implications and validity of nursing assessments based on EMR documentations, the study included 42,302 inpatients admitted for any reason, excluding obstetrics, paediatric and psychiatric patients (Rothman, Solinger & Finlay). The study concluded that nursing assessment, not meeting minimum standards, correlated with significantly higher in-hospital mortality rates.
Nursing assessments are clinically meaningful as it allows you, as the nurse, to establish a condition baseline, and changes or deviation from these assessments can trigger expedited treatments and improve patient's outcome. Performing a correct nursing assessment can also help physicians to improve their patient care.
We are, and must be, frequently assessing our patients, it is the basis for which we set goals for the patient's care. Through assessing your patients both physically and cognitively, by asking questions, talking and establishing rapport, and by auscultating, palpating and observing, you can accurately identify your patient's real needs. What is a nursing head-to-toe assessment?
As you first walk in to see a patient your assessment begins, are they looking at you? Are they responding as you engage in conversation?
Ask your patient's name, why they're seeking medical attention, symptoms (and duration of symptoms), previous medical history, allergies, and current medications.
You then proceed to HEENT and Neurological assessment;
How is their head shape and symmetry, and what is the condition of hair and scalp?
Hows are the conjunctiva and sclera? Are the pupils reactivity to light and is your patient able to follow your finger or a light?
Can your patient hear you? Are they wearing any hearing aids? You should assess their level of hearing by whispering in both ears to see if they can hear and comprehend. Also, do this by turning away to make sure they are not reading your lips. Does your patient have any pain or discharge from the ears?
Check for drainage or congestion, are they having difficulty breathing and their ability to smell.
THROAT AND MOUTH:
Check their mucous membranes, any visible lesions, any missing teeth or dentures? Do their breath stink? Check their ability to swallow (you can do this by having them swallow their own saliva), is your patient's trachea deviated? Any swollen lymph nodes? Check their tongue for swelling and deviation.
Check for level of consciousness and your patient's orientation.
Is your patient awake and alert? Oriented to person, place, time and situation?
CHEST and BACK:
Auscultate lung and heart sounds. Listen for characteristic and quality of sounds, or lack their of. Do you hear the "lub dub" of the heart and clear aeration in the lung fields? You should palpate the chest wall, back, and breasts for any tenderness of lumps.
Observe for any abdominal distention. Listen for the presence of bowel sounds in all 4 quadrants. Palpate for any tenderness or lumps in all for quadrants. Palpate the bladder and assess genitalia. You should also ask your patients about appetite, intake and output, bowel and bladder functions.
Assess your patient's extremities, make sure they don't have any missing limbs. Assess for temperature, capillary refills and range of motion and strength. Palpate proximal and distal pulses. Look for any edema, lesions and wounds, lumps or pain.
As you proceed through the body systems in your assessment, you should be assessing the skin. Observe for any scars, lesions, wounds, redness or irritation. Check skin turgor, color, moisture and temperature.
As you gain experience, your assessment will be faster, but continue to monitor your patients, knowing their baseline and monitoring for changes, positive or negative. Throughout your shift you will continue to perform focused assessments based on patient's conditions and needs. Don't go out and spend crazy amounts of money on fancy nursing equipment if you're not planning to use it. Patient assessment is a fundamental nursing instrument that must be used frequently. Better spend time getting to know your patients than to spend time explaining to their family members or to a judge how you missed their worsening conditions.
The Dude Nurse
Klaus Campos, BSN-RN