So now I am going to get down to the bread and butter of nursing here. The very foundation of nursing upon which pretty much the entire profession rests. There is one activity that even a student nurse learns to do and is hammered home with brutal efficiency. Every nurse does it and every good nurse learns to trust their skills in doing so. That simple skill is performing an assessment. Nurses that know their business can assess a patient accurately in only a few minutes of conversation with the majority done in the first thirty seconds of laying eyes on the patient. I have quite literally seen a nurse peg someone has being in diabetic ketoacidosis by walking into the room and smelling the air. So here I will try to discuss and impress upon people the important role assessment plays at the start and the end of their medical treatment.
An assessment begins the moment the nurse steps into the room or encounters their patient. Now there are the basics of a physical assessment that a nurse pursues. A head-to-toe assessment is pretty much what it says, a very detailed assessment that goes from the head and down to the toes. Typically this is conducted in critical care environments such as an ICU, an emergency department if the situation warrants and in receiving a patient for the first time to the floor. Nurses have many tricks of the trade in doing their assessments here, methods to move quickly and methodically along the patient’s body. This is one reason hospitals like having clothing removed and those annoying hospital gowns placed on the patient. Full access means greater speed and accuracy in doing an assessment. At this time vital signs are going to be checked. Blood pressure, heart rate, temperature, respiratory rate are the highlights along with a pain assessment. I will cover pain later, so for now will simply acknowledge that pain is considered the “fifth vital sign.” In regard to vital signs there is always the question of “is that good” or “what does that mean?” So I will post up the average range of vital signs by the end of this post.
While a nurse is concerned with vital signs out of range, their concern is often different than what the patient might be worried over when seeing the numbers. Nurses are very concerned about acute changes in anything that body does. The rationale behind this concern is that the human body is an amazing machine that compensates surprisingly well. A human being can survive many traumatic injuries, survive a great many problems going on inside and is essentially designed with the goal of survival. One of my most common phrases when talking to other nurses is that everyone is ok, until they aren’t anymore. The best way to tell if a patient “isn’t alright anymore” is an acute change. A sudden drop or rise in blood pressure means the body is no longer able to compensate for something, a change in the heart rate or a rise in body temperature means something is going on inside the patient that the body is having difficulty suppressing. Oddly enough the vital sign no patient asks about and few nurses truly record is respiratory rate, which is one of the key indicators that something is wrong.
Vital signs are finished and our patient is fine on that front. Now the nurse would do two things at once because you never do one thing when you can do many. Truth being told a nurse is probably doing more than two things at once, but we’ll just keep this simple. Nurses are very good at abrupt questions with little shame. As one of my friends told me their favorite part about being a nurse is meeting someone for the first time and questioning them about their bowel movements. So now the nurse is talking to the patient and also starting to truly lay hands on their patient. Typical questions at this point are going to be “can you tell me your name,” “do you know where you are,” “what is today’s date” and “can you tell me why you are here?” These questions actually serve a variety of purposes that a nurse only learns about after school. What a nurse learns in school is that these are the hallmarks of discovering if a patient is orientated to their surroundings. If someone fails to answer one of these questions appropriately, they are considered to be confused to some degree.
Note for any medical personnel – If you are asking the same person these questions several times in a shift, change them up. Confused does not mean stupid. People remember the answers to questions especially if they think answering the questions right will get them a reward such as being discharged from the hospital. A good example of this came from my mother who noticed people were marking down a confused patient was not confused. So she asked the woman where she was and she said the hospital’s name and then my mother asked where that hospital was and she replied with the wrong state, country and even planet. So obviously confused still.
I will also say this is not the time to be cute or funny. Some patients like to become a smart ass at this point and while usually humor is appreciated there are obviously certain times when a serious response is necessary. Pretending to be confused can have some serious consequences and do remember a nurse is always charting. So anyway.
This is likely also a good time to diverge into the two types of information a nurse collects. To those that do research or have some involvement in a scientific area these types will sound familiar, subjective and objective information. Subjective is information that I, as the observer, cannot state that I witnessed myself. Typically in the charting this goes down as patient states, family member states, etc. Such types of information include pain, background information, responses to certain questions and so forth. Anything that the patient tells the nurse about themselves or that someone else tells me about the patient is subjective. Objective information is something that I as the observer can witness and state was observed by me in some fashion. Bruises, erratic behavior, blue nail beds, etc. So there you go, real science for nurses.
Now I could fill pretty much an entire book with every detail being checked during a full head-to-toe assessment. In fact there are books filled with this information and actually an entire class is devoted to just doing a head-to-toe assessment in nursing school. As I said, this stuff is hammered into a nurse with brutal efficiency. Also a nurse is not going to chart everything that is found. Most nurses do what is called charting by exception which means they take note of anything out of the ordinary. As I said, we are looking for acute changes typically.
From head-to-toe a nurse will move toward another type of assessment, the focused assessment. Now keep in mind that a head-to-toe is not always warranted. Showing up to the clinic, you will likely not be getting naked. Coming into the Emergency Room for a stubbed toe or Urgent Care, more than likely a focused assessment is what you are getting. A focused assessment is also similar to what it sounds and the nurse puts their attention on the problem stated. This is why a triage nurse or doctor is trying to get their patient to give them a main complaint or “chief complaint.” Obviously attention directed into one area is more accurate than spread out over a multitude. Plus, as I said, acute changes more serious than complaints someone has had for weeks, months and even years. Also if a patient had surgery on their knee, this is where I want to look as the greatest risk to the patient is going to come from where we were messing around. Anyway…
Focused assessments are also variable by complaint and by nurse. Experience plays a large part in what a nurse does and has learned works best. Not all nurses operate the same, but that is not to say that one nurse’s methods and style are better than another. A good nurse alters their style to what suits the patient best and what serves the needs of their patient. Nursing is about taking what has to be done and altering that necessity to the problem presented. This is one reason that no matter how thorough a charting system is designed, nurses ALWAYS need free texting. Because, to be honest, there is some shit you just can’t design for in healthcare setting. I tell you this because I do not want you, as a potential patient or family member to a patient, to become too upset or worried when a nurse comes into the room and does something different.
Once more, going into detail about all the focused assessment types and styles and methods and so forth would be a massive undertaking here. Odds are I would also be wrong in many cases because I do not have experience in all specialties.
So maybe now you are asking why I even bothered with this post since I cannot truly go into depth about all this stuff? Because as I said at first, this is the foundation for all nursing. Performing an assessment is quite literally the first thing a nurse does and the last thing a nurse does for their patients. This also extends beyond a single patient and moves into every aspect of nursing. A community health nurse does an assessment on their community, an administrative nurse evaluates their units on similar criteria and so forth. Assessment is the cornerstone and bed rock of this profession. If you are going to understand the thought process of a nurse, then there can be no understating the value of how this skill set and mentality plays on them.
When in doubt about a situation, nurses will assess. Assess before action. Why? Because I can always re-assess, but if my action kills you because I did not properly assess the situation then I can’t redo that action.
So until next time. Stay healthy and be nice to your nurses!