Assessment is, hands-down, the MOST important skill a nurse has. Of course, you will do your head-to-toe assessments at scheduled intervals depending on the acuity of your patient…but assessment doesn’t stop there…It is something you do every single time you interact with your patient.
Regardless of whether your patient is in the hospital for surgery, pneumonia or abdominal pain…if you do these five simple assessments every time you walk in their room, you’ll learn a lot of information and always stay on top of your game. Of course, don’t limit yourself to these five things….this is what I’d consider the basic minimum to do with every interaction. If you need more data, get it…if you don’t, then these five things should suffice just fine until the next time you take vitals or do a full head-to-toe.
Assessment #1: Pain
I’m not saying you need to bombard your patient with the “what is your pain on a scale from 0-10” every single time you talk to them (though technically you are supposed to do this every hour). What I mean is that you can learn a lot about a patient’s pain level by watching them…how do they move, are they able to take a deep breath, are they guarding or limiting movement, are they grimacing or moaning? Look for signs of pain with every interaction…if you see any, then by all means ask. A lot of patients refuse to take medication because they don’t want to get addicted. You will do a lot of patient education on this topic, I promise!
Assessment #2: Respiratory Status
No, you don’t have to get out your stethoscope every single time you walk into your patient’s room. Just watch and listen. Are they working hard to breathe? Are they breathing really fast or really slow? Is their breath labored or noisy? Are they gasping? Are their breaths really shallow? Are they only able to speak a few words at a time? Do they sleep propped up on pillows? Are they assuming the tripod position? If you can answer “yes” to any of these, you’ll want to do a more in-depth assessment.
Assessment #3: Skin Signs
Assessing skin signs is a quick way to monitor cardiovascular and respiratory status. You’re looking for your patient to be warm, dry and the appropriate color for their race. Any signs of diaphoresis, mottling, paleness, duskiness or clamminess (is that a word?) are cause for concern.
Assessment #4: Urine Output
If your patient has a Foley catheter, take a peak at their urine output…it should equal 0.5ml/kg/hr or roughly 30 ml per hour. Again, I’m not saying you need to measure it each time you go in the room….just eyeball the container. You’re looking for straw colored urine in the appropriate amount. Anything else should be investigated.
Assessment #5: Level of Consciousness
Checking the patient’s LOC is another key assessment. Are they alert and oriented? Are you able to have a conversation that makes sense? Do they answer questions appropriately and follow commands? As you learn the skill of assessment, you’ll learn that you don’t have to be so formal as to say “show me two fingers” to know if most patients are following commands. Simply asking them to hold their arm out for a blood pressure cuff, or open their mouth for the thermometer is testing their ability to follow commands. If anything seems off, then do a more thorough neuro exam. See how easy that is?
As you go through your clinical rotations, work at incorporating these five simple assessments into your patient interactions. You’ll be surprised how much data you can obtain and how it easily becomes second nature. You got this!