Login


Register | Recover Password
 

Physical Assessment & Report

Snapshot: This article reviews the fundamentals of physical assessment. Note: This information is for reference purposes only; vital signs must always be interpreted in the context of a broader clinical assessment.

  • Read the chart before you start. One of the most helpful things you can do before you get report is to read through and take notes from the patient’s history and physical (if they have one), and the most recent progress notes. The history and physical (H&P) provides a ‘snapshot’ of the patient’s diagnos(es) and recent hospital course; the most recent progress notes provide information about recent clinical changes and the patient’s plan of care. By reading the chart in this way, you can form a mental ‘picture’ of the patient and can gain more from the verbal report you receive.
  • When you get report, trust but verify. To some extent, we all have to trust one another as nurses when we hand off and receive patients from one another. That said, never blindly accept anything you hear in report; as you’ll learn (perhaps the hard way) there can be big discrepancies between another nurse’s report and your own assessment of the patient. Even if all of the information you receive in report is accurate, the patient’s clinical picture may have changed by the time you complete your assessment. Getting report should never be a substitute for your own good judgment, observation, and critical thinking.
  • Prioritize your patients. After you receive report, you need to decide which patients to see first, second, third, and so on. Consider the following to prioritize your assessments: acuity of illness, your familiarity (or lack of familiarity) with the patient, any recent changes in the patient’s health status that you received in report or saw in the chart, planned procedures (i.e. will the patient be off the unit before you can complete your assessment?), and so on. If you’re having difficulty prioritizing, you can also quickly ‘check in’ on each of your patients just to make sure they’re doing alright before you return to complete your assessment. Remember, once you receive report, from a legal standpoint you have assumed responsibility for your patients; whatever system of prioritization you develop, keep this important principle in mind.
  • Your assessment starts when you walk in the room. You can glean important clues to your patient’s health status before you begin the physical assessment. How is your patient sitting in the bed? Does he or she appear to be in any distress? Are there visitors present, and if so how is your patient interacting with them? What is your patient’s emotional state, and how does it relate to their physical appearance? These are all questions you’ll unconsciously begin to ask, and answer, to provide a framework for your assessment.
  • Focus your assessment, from head to toe. In nursing school, you probably learned how to do a ‘textbook’ head to toe assessment, moving through each body system to evaluate your patient. While you should retain the head to toe approach, the reality is that you simply won’t have time for a linear system-by-system assessment for each of your patients. Instead, you’ll need to learn to complete comprehensive yet ‘focused’ assessments, by honing in on the most important body systems for your unique patient population. Ask yourself: which systems are the most crucial to this particular patient, and which are most likely to deviate from normal ranges? Which body systems provide the most important insights to the health status of this patient, and patient population? This doesn’t mean you should ignore any body system, but it does mean you must think critically to prioritize your assessment of those systems (much as you must learn to prioritize the needs of your various patients).
  • Breath sounds and pulses. No matter what patient population you work with, auscultating your patient’s breath sounds and palpating their pulses are crucial assessments. Here are a few quick tips to aid you. It may sound funny, but when you’re listening to breath sounds, close your eyes; doing so will help focus your auditory senses (your ability to hear) by closing down your visual senses (your ability to see); in short, by closing your eyes you’re more likely to concentrate on what you’re actually hearing, not what you think you’re hearing or have been led to think you’ll hear based on the patient’s chart or the report you received. As you move down the patient’s body and palpate pulses, pay attention not only to the strength of the pulse, but also to the warmth and sensation of the extremity (i.e. arm, leg, foot, etc) where you’re feeling the pulse. If you palpate a thready pulse on an extremity that is noticeably cool and dusky (pale), this is much more concerning than if you palpate a thready pulse on an extremity that is warm and appears well-perfused. If you’re uncertain how to interpret these signs, you can also always compare how the pulse and extremity compares on one side of your patient’s body to the other side; if there is a notable discrepancy, this is also a warning sign that merits further investigation.
  • Assess the patient, not the numbers. You’ve probably heard this before, but the more experience you gain as a nurse, the more you’ll come to realize how important this fact is. If, for instance, a patient’s vital signs look concerning, your first instinct should always be to pay attention to what you see – that is, to assess the person in front of you. Are they in distress? Do they appear short of breath? How are their pulses and perfusion? What is their mental status? A blood pressure of 85/60 may be great cause for concern for one patient, and relatively little cause for concern for another. Numbers – vital signs, lab results, and the like – can only ever be markers of health, not determinants of care.
  • Know your patient’s baseline. Closely connected to the above observation is the fact that every patient has a ‘baseline’ – that is, a state of health that is relatively ‘normal’ for that patient. Among the most important questions you can ask about almost any clinical scenario in question, then, is whether the health challenge your patient confronts is acute or chronic (that is, of new onset or long duration). A patient whose oxygen saturation is chronically 88 – 90% on room air (perhaps due to COPD or some other obstructive respiratory condition) is of much less concern than a patient whose oxygen saturation is typically 97 – 100% on room air and suddenly drops below that level. Get into the habit examining not only individual vital signs and lab values, but trends in these values over time; consider, moreover, how those vital signs and lab values relate to the underlying pathophysiology of the disease processes your patients confront. Doing so is the difference between recognizing and failing to recognize meaningful changes in your patients’ health status.
  • Understand why, not just what. Superficially, nursing is a task-oriented job; to some extent you can get by if you stick to medication parameters, your institution’s procedures, and the like. But you can’t really be effective for your patients unless you understand why you’re doing what you’re doing, not just what. You may be surprised how much others – patients, patients’ families, physicians, and other healthcare professionals – turn to you for insight and recommendations. It’s difficult to be an advocate for your patient, to spot and correct errors, or to actively participate in your patient’s plan of care unless you understand the reasoning behind what you’re doing.
  • Documentation is key. As you move through your day, it can be easy to push aside documentation to focus on more immediate tasks and problems; some days, that’s inevitable. Keep in mind, however, that from a nursing, medical (and legal) standpoint, it’s absolutely true that ‘if it wasn’t documented, it wasn’t done.’ Documentation isn’t secondary to your nursing practice; it’s central to it. Moreover, as you’ll discover, the longer you wait to complete your documentation the less accurate it becomes; by the end of the day your assessments from the beginning of your shift get lumped together in your mind, and you’re more likely to omit information or make other errors. As you gain experience, practice documentation that is as accurate and as timely as possible.
  • Use SBAR to give report. While there’s no ‘one’ way to give report to another nurse on a patient, you may find it helpful to use the SBAR (situation, background, assessment, recommendation) format that has become a standard for medical communication of all kinds. Using SBAR will help you organize your report and make it understandable. Your patient’s ‘situation’ is their current diagnosis or presenting complaint, their ‘background’ is their recent hospital course (including pertinent recent tests and procedures), their ‘assessment’ is your head to toe (that is, each body system) assessment of the patient, and your ‘recommendation’ is your interpretation of the patient’s plan of care (that is, next steps for the patient, including possible discharge planning).
  • Give yourself a break. If you’re a new nurse (and if you’re reading this you probably are), keep in mind that all of these tips constitute optimal practice; even many seasoned nurses fall short. Give yourself time (at least a year or so) to become comfortable and confident in your assessments, and your nursing skills generally. Until you practice these skills, and make some inevitable mistakes along the way, you won’t really learn. What these guidelines can hopefully do is to provide you with a better framework for learning, so that when you encounter clinical challenges you’ll be more likely to learn from them and gain insight into your practice. Nursing is very hard work; give yourself as many breaks (both mental and physical) as you can as you go along. If you’re too hard on yourself you’re at risk of burning out before you can gain the experience that will be your best teacher.