Patient assessment is an essential skill for med surg nurses to master. It’s a critical component of providing top-notch care and ensuring positive patient outcomes. This comprehensive guide will walk you through the practical steps, share helpful tips for success, and offer advice on documentation. Let’s dive in!
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Step-by-Step Guide to a Thorough Patient Assessment
Start with a Systematic Approach
Having a systematic approach is crucial when performing patient assessments. This helps ensure you don’t miss any essential details. A popular method is the head-to-toe assessment, which involves evaluating each body system sequentially, starting from the head and working your way down.
Think of it like a golf swing🏌️ Do it the same way every single time.
Gather Information from Multiple Sources
While conducting your patient assessment, you must consider information from various sources to paint the entire clinical picture.
Consider the information from the following sources as you walk through your golf-swing. These will accurately paint the picture of the current situation you’re dealing with.
- What the off-going nurse told you
- Current chief complaint and main issues – if you’re familiar with the disease process, the assessment findings can be predictable
- Recent labs and vitals – merely scan these from the chart
- What you’re physically seeing with your eyes as you look at the patient
- What the patient and/or loved ones are telling you
- Previous assessment findings in doc flow, H&Ps, and physician progress notes
Perform Vital Signs and Pain Assessment
Begin by checking the patient’s vital signs, including temperature, pulse, respiration rate, blood pressure, and oxygen saturation. In addition, assess their pain level your standardized scale and make sure you document it. ⭐ BONUS ⭐ if your nursing unit has a standard practice in which certified nursing assistants (CNAs) get vital signs prior to assessments and you can just review these data points, rather than having to collect them yourself.
Pro-Tip ➡️ I like to perform a quick pain assessment when receiving bedside report from the off-going nurse. I simply ask, “Hey how’s your pain right now on a scale of 0-10?” That way, if they have pain and require an intervention, I can bring that in with me when I come back for my full assessment. This clusters care and reduces trips to the med and supply room.
Evaluate the Neurological System 🧠
Your neuro check begins the moment you walk in the room. Do they notice you? Are they able to focus on you with both eyes equally and engage in normal conversation? Do they use all extremities equally and purposefully?
Check the patient’s level of consciousness, orientation, and ability to follow commands. Assess their pupils for size, shape, and reactivity to light. If they have any baseline neurological deficits, you’ll want to perform a more detailed neuro check. I go through how to do that in the free email course listed below.
Inspect the Respiratory System 🫁
Listen to the patient’s breath sounds and observe their respiratory effort. Assess for any signs of respiratory distress or changes in their breathing pattern.
I personally love this stethoscope for auscultating heart, lung, and bowl sounds.
Tips for Listening to Lung Sounds 🩺
Auscultating lung sounds is a crucial part of a physical examination to assess respiratory function. Before listening, clean the scope, ask for permission to listen, and ensure privacy. Here are some tips to help you perform this technique effectively:
Environment: Turn off or mute the TV, close the door to minimize background noise
Patient positioning: Ask the patient to sit upright with their arms relaxed at their sides. If this is not possible, have the patient lie down in a supine or lateral position.
Expose the chest: You’ll hear better if your scope is directly on their skin. Rather than ripping open their gown, you can slide the scope under the gown without removing the gown entirely.
Systematic approach: Listen to the lung fields in a systematic manner, starting at the apices and working down to the bases. Compare the sounds on each side of the chest to identify any differences.
Anterior and posterior chest: Make sure to auscultate both the anterior and posterior chest areas for a comprehensive assessment. Remember to listen to the lateral chest as well. If the patient is a total care patient, listen to lung sounds when giving the patient a bath with your CNA so they can hold the patient on their side while you listen to posterior lung sounds.
Proper stethoscope placement: Place the diaphragm of the stethoscope firmly on the patient’s chest without gaps, but don’t press too hard, as this may create additional sounds.
Breath instruction: Instruct the patient to breathe deeply and slowly through their mouth. This helps to emphasize any abnormal lung sounds. Try to listen to a full inspiration and expiration in each place. Remind the patient to be relaxed and not rush. A reassuring hand on their shoulder while listening can be helpful for anxious patients.
Identify normal breath sounds: First, focus on being able to distinguish normal versus abnormal. You want to hear good and clear air movement.
Recognize abnormal lung sounds: Learn to identify common abnormal lung sounds such as wheezes, crackles (rales), stridor, and pleural rubs.
Assess the Cardiovascular System 💖
Check the patient’s heart sounds (using similar tips as above!), peripheral pulses, and capillary refill time. Note any signs of edema or skin color changes that may indicate circulatory issues. If the patient is on telemetry, check the rhythm as well.
If you’d like a full in-depth cardiac assessment walkthrough, click here.
Examine the Gastrointestinal System
First, listen to bowel sounds in all four quadrants starting at the ileocecal valve, where it willy likely be the loudest (right lower quadrant). They should sound like a tinkling sound. You want to hear it in all four quadrants. You may need to listen for a little while in each spot to hear it. Once done listening, then gently palpate the abdomen and inquire about tenderness or pain, and note any distention or masses.
Finally, ask about their appetite, nausea, or vomiting.
Assess the Genitourinary System
If the patient has a urinary catheter, make sure it’s functioning properly. If they are voiding normally, you can ask something like, “How is it going to the bathroom? Are you having normal bowel movements and does it feel normal urinating?” If you’re able to assess urine, check for clarity, color, sediment, and odor.
Inspect the Integumentary System
Examine the patient’s skin for color, temperature, moisture, and any lesions, rashes, or wounds. You can do this throughout the assessment.
Pro tip ➡️ Double-check their chart to see if there are any wounds documented so that you don’t forget to check those out.
Evaluate the Musculoskeletal System
Assess the patient’s range of motion, muscle strength, and any signs of pain or swelling in their joints. If the patient walks to rest room or around the room during your assessment, this gives you a plethora of information about their musculoskeletal system.
You can ask how they feel moving around, and how it has felt getting up with therapy or simply getting into the chair or walking to the rest room. If bed bound, you can assess this by asking them to squeeze your hands and then asking them to push and pull your hands. Finally, you can check dorsi-plantar flexion by having them push down on your hands with their feet and pull back by flexing their toes towards their nose.
You can say something like, “Push down on your feet like you’re pushing on the gas pedal!” while you have your hands against the soles of their feet.
Then, say “Ok, now bring your toes up towards your nose!” with your hands laying on top on their feet.
Pro-tip ➡️ Always do the feet stuff last. It’s kind of gross to touch someone’s toes and then touch their hands or face. End with the toes, then remove gloves and wash hands.
Tips for Success in Patient Assessment
Develop a Routine
Having a consistent routine for your patient assessments can help ensure you don’t miss any crucial information. Practice your routine until it becomes second nature. At first it will be clunky and you’ll feel like you look ridiculous, but with time you’ll be able to fly through it with ease.
Communicate with Your Patient
Ensure you explain each step of the assessment process to your patient. This helps them feel more comfortable and can encourage them to be more forthcoming with information.
Use Your Intuition
While a systematic approach is essential, don’t forget to rely on your intuition as well. If something feels off, take the time to investigate further. Abnormals can be investigated, but an important point to remember for new graduates: It will take time to develop your intuition. At the beginning, it’s difficult to decipher anxiety from a “gut feeling”. Your intuition muscle will strengthen with time.
Collaborate with Your Team
If you’re seeing something concerning, first look in the chart and compare it with the previous nurse’s assessment. Also check the last provider’s note and pay particular attention to their assessment to see if it matches up. If you’re still concerned, chat with a fellow nurse or charge nurse and get another set of eyes on the patient and talk through what’s goin on. Even if nothing is wrong, talking through something you don’t fully understand with a colleague is immensely beneficial for your learning.
Documentation Tips for Med Surg Nurses
Be Concise and Accurate
Include only relevant information and use objective language. Do not put your feelings or assumptions in the chart. For example, if you walk into the patient’s room and see them on the floor and they told you they fell, you should only chart what you saw.
Not: “Patient fell.”
Rather: “Upon walking into the room, patient was lying on the floor at the doorway of the bathroom. Patient stated that he fell.”
Document in Real Time
This helps prevent errors and ensures accurate record-keeping. My time-saving tip is to chart only your abnormal assessment findings in real time immediately after the assessment, and then save those items you chart on everyone (the “normals”) after all patients have been assessed and medicated.
Use Standardized Terminology
When documenting your patient assessment, use standardized nursing terminology to ensure clarity and consistency in communication among healthcare professionals. When you’re using the chart, you must use the approved list. Your hospital likely has one that is part of their policies.
More Resources for Med Surg Nurses
As you continue to develop your patient assessment skills, it’s essential to have access to reliable resources. Check out these helpful FreshRN resources to further enhance your knowledge and expertise:
In conclusion, mastering the art of patient assessment is a vital skill for med surg nurses. By following a systematic approach, utilizing tips for success, and ensuring accurate documentation, you’ll be well on your way to providing top-quality care for your patients. Don’t forget to take advantage of the resources available to support your ongoing learning and growth in this critical area of nursing practice.
Are you a new Med-Surg nurse?
Med-Surg Mindset from FreshRN is the ultimate resource for nurses new to this complex and dynamic acute care nursing specialty. Whether you are fresh out of nursing school or an experienced nurse starting out in med-surg for the first time, the learning curve is steep. With input from three experienced bedside nurses, this comprehensive course is all you need to learn all of the unspoken and must-know information to become a safe, confident, and successful medical-surgical nurse.
