01.03 The 5-Minute Assessment (Physical assessment)

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The 5-Minute Assessment (Cheat Sheet)
Head to Toe Assessment (Cheat Sheet)

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One thing we see and hear from students all the time is that they struggle to be fast and efficient with their head to toe assessment during clinicals. They get bogged down with the details of assessing each body system and it takes them 20, 30, or even 45 minutes on one patient. Well, when you’re in a med-surg unit and you could have 5 patients, you can’t take 30 minutes per patient to do your assessment! What we want to show you here is what a REAL shift assessment looks like in practice. And we’re going to show you how to do it in 5 minutes! Doing a full shift assessment in 5 minutes is all about multi-tasking. This video will show you what the assessment actually looks like - and the outline in your lesson will show you what OTHER information is being gathered simultaneously. For example, you’ll be assessing skin color, temperature, lesions, and pain throughout your entire assessment! The big thing here is - gather your information - if you see something is off, pause and investigate it further - do your pain assessment, assess a wound in more detail - then pick right back up where you left off! When you’re done, get a full set of vital signs and document your findings! Let’s see what this looks like in action!RN: Hi Miss Haws, my name is Nichole, I’m going to be your nurse today. I just need to do a quick assessment to start the shift, is that okay?Pt: Sure!RN: Great, just a few questions we ask everyone. Can you tell me your name?Pt: Tammy HawsRN: Can you tell me where we are right now?Pt: In the hospitalRN: Can you tell me what month it is?Pt: DecemberRN: Great! What brought you into the hospital today?Pt: I had to get some tests run on my heart.RN: Okay, I see. Well I’m going to start the physical part of the assessment now. If anything I do or ask you to do causes you pain, you just let me know.Pt: Okay.RN: ((Assesses pupil response (PERRLA)): Bright light, just look straight at my nose. ((Looks quickly in nose and mouth)): Open your mouth, stick out your tongue. ((Assesses ears)): Turn your head to the left, now to the right. ((Assesses visual fields)): Follow my finger with just your eyes.Pt: ((follows commands))RN: Are you having any pain or issues with your head, neck, jaw, or ears?Pt: NopeRN: Great, I’m just going to listen to your heart, lungs, and belly now. Just breathe normally for now. ((Assess heart sounds)). Now take a deep breath in and out when you feel my stethoscope on your chest. ((Assess lung sounds - quickly press on chest to assess for crepitus, pinch chest for turgor)). Okay you can breathe normally, I’m going to listen to your belly now. ((Assess bowel sounds)). Any pain when I press your tummy? ((Palpate 4 quadrants)).Pt: NoRN: Great. Can you squeeze my hands? ((Grip strength)). ((Assesses radial pulses & cap refill)). Lift your hands up like you’re stopping a bus, now push against me. Now, pull me towards you. ((Assesses strength)). Can you lift your hands out to the side? Now over your head? ((Assesses ROM)). Great - you can put them down now. Any pain with those movements?Pt: NoRN: Great, I’ll move on to your legs now. ((REMOVE SOCKS. Assess pedal pulses, cap refill - and edema)). Can you push down on my hands like a gas pedal? - Pull your toes toward your head. Great. Now, lift your legs off the bed, and don’t let me push them down. Great job. Can you bend your knees for me?Pt: ((Bends knees.)) YesRN: Awesome, now, I need to assess your back - can you turn to one side for me? Pt: ((Turns to side)). SureRN: Can you take a deep breath when you feel my stethoscope? ((Assess lungs on back)). Just need to check your skin. ((Assess skin on back/butt)). Okay, you can turn back over now.Pt: OkayN: Have you had any issues with pain or burning with urination?Pt: NoRN: Great - we’re just going to get a full set of vital signs and then get the rest of the shift started. Is there anything else you need right now? Pt: NoRN: Great.We hope this was a helpful overview of how to do a quick 5-minute shift assessment. Did you notice the nurse checked turgor on the chest WHILE she was listening to lung sounds!? Again, it’s all about multi-tasking. If you find something abnormal, that’s when you use what you’ll learn in the body system-specific assessment lessons to investigate it deeper. Now, go out and be your best selves today. And, as always, happy nursing!

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