Assessment Practice

Hi!! I am in my first semester of nursing school, so I'm just learning the ropes of everything. I start clinicals in two weeks, and am so nervous :uhoh21:! Right now in my fundamentals class I am having some trouble with what all goes into the assessment, and how to distinguish what's abnormal, along with how to document in all properly, and so on.. I think if I could get some practice assessment worksheets, then that would be a good way for me to practice what all I need to be looking out for, and what my responsibilities are in the assessment. I learn best by writing things out so I'm thinking this would be key for improvement. Let me know of places where I could find such a thing, and/ or any helpful insights you might have thanks!!!
Hi there!I suggest doing practice assessments on everybody you know. Do a head to toe on your mom, dad, bro, sis, boyfriend whatever. Also when doing a head to toe, think of the big systems. 1. Mental status-ask patient for name, hospital name and date2. Listen to heart/lungs3. Abdomen(bowel sounds/bladder distension)4. Check Gu status(catheter in place etc.)5. Check pulses/lower extremeties(swelling etc.)6. Check IV sites, Picc line sites etc. for s/s of swelling, bruising etc....Then look at the equipment in the room...IV pumps, foley, feeding pump etc. and be sure there are no issues there.That is a real life head to toe in the hospital setting. Good luck to you!!

Here is an attachment of head-to-toe assessment. It is a little detail for your first time clinical visit but there is a simplified version once you scroll down to the bottom.Enjoy your clinical rotation and best of luck!!!

Quote from Miller86Here is an attachment of head-to-toe assessment. It is a little detail for your first time clinical visit but there is a simplified version once you scroll down to the bottom.Enjoy your clinical rotation and best of luck!!!

By second semester you will be competent. I think the pressure to learn certain material can be a competency killer. I passed my assessment check off, but did not feel competent at all; it was mostly based on memorization. But now I'm in my second semester and feel very good about my assessment skills. The technique that seemed to work for me was to voice record myself going through all the steps of assessment. During playback, pretend that I was the instructor and compare my voice recorded assessment with my check off sheet. I would do this until I consistently got it right.

I found some advice on here my first semester and I used it. Our instructors gave us like a complete head to toe check off so you do not forget any areas. It did not list abnormals or any thing but I took this list and shrunk it down and taped it to my clipboard. I found this tip on here a long time ago! I also have used this method for things such as the different needle gauges and lengths and what areas they are used in. This way I have a "cheat sheet" I can always take to clinicals. Also, at the facility I currently do clinical in they do not use computer charting so we all got blank copies of their flow sheets which have their own version of a head to toe and we can take these copies into the room while doing the assessments. This helps me with my documentation because I know more of what the facility expects. Our nursing program did not focus on abnormals the first semester, we were just basically learning the process. This semester we have gotten into the abnormals. But if you look onine you can find all sorts of free resources for head to toes! Good luck and don't worry you will be fine!