This is one of the things, as a new nurse, that keeps me awake at night. I have a fear of missing something critical that will harm the patient and doing harm is not my intention.
Nurse Mentor Nancy’s reply:
Before we talk about assessment, let’s define the term and explain how it fits into the nursing process. Assessment, as the first step of the nursing process, consists of gathering information and making observations. Information coming from the patient, his family or caregivers is called subjective data. Information and observations obtained from a physical exam, tests and the medical record is called objective data. RNs analyze this information in order to decide the actions they need to take for the patient. Follow these three suggestions to improve your ability to gather and analyze assessment information.
1. Learn what acute and chronic illnesses are most commonly seen in your clinical specialty.
Look up the risks, signs, symptoms and treatment for those illnesses. Learn what questions need to be asked and what physical exams and tests are normally done. The reference books you find most helpful will partly depend on your clinical specialty. If you go online for information, make sure the reference dates at the end of the article are within the last few years. Otherwise, you may be looking at outdated information. I use http://emedicine.medscape.com/. An assessment book is helpful. I like Bates’ Guide to Physical Examination and History Taking because of the examples highlighted in red on each page of the chapter and the pictures of abnormalities at the end of each chapter. To save money, you do not have to buy the latest edition or a brand new book. I bought a used ninth edition on one of the online bookstores.
2. Latch on to a mentor with good assessment skills
Nothing is better than watching someone else go through the process. If you know a experienced nurse who is good at assessment and analysis, ask to tag along. Listen to this nurse ask the patient questions. Look at what other information is obtained and from where. Pay careful attention to the exam that is done. Even better, repeat the exam after wards. Compare what you hear or feel with what this nurse hears and feels. If possible, make rounds with a nurse practitioner, physician assistant or physician. Videos and audiotapes of physical exams, heart and lung sounds can be helpful, too.
3. Take good notes
Get a small notebook you can fit in your pocket. When you take care of a patient with a disease you are unfamiliar with, write down any questions you have. Look the answers up later. In the future, when you get a patient with similar symptoms, you can refer back to your prior experience. Eventually, if you routinely use this information, you will know it by heart and will no longer need this book.
If you follow these steps and take advantage of the opportunities you have in your day to day practice, you will become good at knowing what assessment information to gather and how to analyze that data. You will be less likely to miss any critical changes in your patients. That does not mean you won’t make mistakes. What is important is that you learn from them. You can never know everything. So continue to ask questions, look up anything you don’t know and always be willing to learn more.