Assessment & Documentation

One of the hardest thing for me to learn, so far in nursing school, is assessing my patient and then documenting my subjective and objective data.

It’s not that it’s a hard concept for me. Assessing a patient basically means learning how to take a history of/examine a patient and look for normal/abnormal findings, subjective information is what the patient tells you, and objective information is what you gather from your own physical assessment of the patient. But the first problem for me is that it takes me positively FOREVER to complete a focused assessment on my “patient”; I have to reference my book every two minutes, I’m slow and clumsy, and I feel like I just don’t know what I’m doing. I definitely DON’T feel like a nurse; I feel like I’m a bumbling idiot, and it will take nearly an hour, maybe more, of the allotted lab time for me to complete my focused assessment. :-/ Then I feel bad because if I went first, my lab partner is rushed in order to finish on time when she’s doing her assessment on me.

The second problem is that it’s hard for me to document my data in a brief, efficient, concise, yet flowing way that my instructors (and eventually hospitals) want. I don’t think it’s a complicated task…yet somehow it will take me 1.5-2 hours to do when I get home and start my “charting” – and I really need to get it down to about 30 minutes tops (for head-to-toe assessments) and 15 minutes tops (for focused assessments). Eek!

Here is an example from about two weeks ago, when we were covering the lungs/thorax in lab. Remember that this is not a real patient – it’s all made up for learning purposes. After I charted this and submitted my charting, my instructor told me it was really good, but still too long. I need to be able to mince my thoughts yet still be efficient in getting my assessment findings across:

Subjective

A 20-year-old Caucasian female presents with c/o a cough. (T) Patient states cough began on February 4, 2013. “It just happened; I woke up that morning coughing out of nowhere.” Patient states that cough has been consistent since then, with coughing spells occurring briefly every half hour throughout day. (Q) Describes cough as wet/productive and congested in the morning but dry and hacking in the afternoon and evening. States the quantity of cough as mild to moderate intensity. (S) Severity of cough a 5/10 in morning and a 3/10 in afternoon/evening. (P) Patient states that no activity exacerbates cough. Patient took one Mucinex in the morning of February 6, 2013, however, “the Mucinex was a waste of money,” as it does not seem to be helping. Patient denies taking any other OTC medications. (R) Patient denies chest pain upon breathing or coughing, only general tightness in the region of the sternum. Patient rates tightness as a 2/10. (U) Patient states cough has not affected ADLs as she has been able to go to nursing school classes as she usually does. Patient believes she has a cold; “I just want to make sure I don’t have anything worse that could make someone else sick.”

Patient denies shortness of breath, no past history of lung diseases, denies tobacco use and exposure to environmental irritants at work. Last TB skin test November 2012 with negative results, flu vaccine November 2012 with no adverse reactions. Denies ever having a chest x-ray done.

Objective

Posterior Inspection: Transverse to AP diameter 2:1. Spinous processes straight, thorax and scapulae symmetric bilaterally. Appropriate development of neck and trapezius muscles for age; no use of accessory muscles. Position relaxed and upright with arms at sides. Breathing effort even and unlabored with 14 respirations per minute. Skin color light beige, even tone – consistent with genetic background. No lesions on skin noted.

Anterior Inspection: Ribs sloping downward with symmetric interspaces bilaterally. Costal angle within 90 degrees. Development of abdominal muscles appropriate for age; no use of accessory muscles. Facial expression eager, A&Ox3 and cooperative. Lips and nailbeds pink, free of pallor and cyanosis; approx. angle on nailbeds 160 degrees. Skin color light beige, even tone – consistent with genetic background. No lesions on skin noted.

Posterior Palpation: Symmetric chest expansion bilaterally. Mildly increased fremitus on right side. No tenderness, lumps, bumps, or masses noted upon palpation of chest wall and spinous processes.

Anterior Palpation: Fremitus symmetric bilaterally. No tenderness, lumps, bumps, or masses noted upon palpation of anterior chest wall.

Posterior Percussion: Resonance dominate over lung fields bilaterally upon percussion.

Posterior Auscultation: Clear bronchovesicular breath sounds at level of ICS T1-T4; moderate pitch with mixed quality. Clear vesicular breath sounds at level of ICS T5-T10; low pitch with soft quality. All breath sounds equal bilaterally. Lateral left side – clear breath sounds, low pitch and soft quality, at level of ICS T3 and ICS T5 midaxillary line. Lateral right side – clear breath sounds, low pitch and soft quality, at level of ICS T3, T5, T8 midaxillary line. No adventitious sounds present.

Anterior Ausculatation: Clear bronchovesicular breath sounds, moderate pitch with mixed quality, at level of ICS T2, T3. Clear vesicular breath sounds, low pitch with soft quality, at level of ICS T7. All breath sounds equal bilaterally. No adventitious sounds present.

When we have our Head-to-Toe Check-Offs at the end of the semester in Assessment, we will have 30 minutes to complete a head-to-toe physical assessment on our partner, and then 30 minutes to sit down and document EVERYTHING. I know the end of the semester is forever away, but let’s just say I’m already nervous and stressed about this check-off! I can barely assess my patient with my book and lab guide in front of me, how am I supposed to just pull everything out of my head and know when/how to assess? How am I supposed to document a complete assessment in 30 minutes when it takes me over an hour to document a focused assessment?

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4 thoughts on “Assessment & Documentation

  1. I felt the same way last semester when I was doing head to toe assessments on my partner. We had to write EVERYTHING down and it took me forever and was ridiculous. But by the end of the semester it will not take you long at all, I promise. You’ll be able to write things down from having done it so many times before. And once you get to the hospital, you won’t need to do this type of detailed charting either. It’s mainly charting by exception! So don’t worry!

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