general
What is the purpose of a head-to-toe assessment?
To systematically assess the ENTIRE patient to ensure no data is missed.
T/F: if it's not documented, it didn't "happen"
TRUE (documenting is a legal document. if it were to be used in court, and something wasn't charted it legally did not happen)
the RN is very busy and documents "skin is cold to touch". What is wrong with this documentation and how can it be improved?
lacks specific descriptors, AND this is an abnormal finding, which needs to be elaborated on. This can be fixed by including comparison, location, or associated findings
A nurse assesses heart and lung sounds while examining the chest. This reflects:
A. Focused assessment
B. Fragmented assessment
C. Simultaneous assessment
D. Emergency assessment
C
What is the VERY FIRST action before initiating a physical assessment? (why?)
Hand hygiene
What type of language should be avoided in documentation?
Bias, opinions, or judgmental language.
During assessment, the patient becomes fatigued and asks for a break. The RN has 4 other patients to assess within the hour.
Question: What is the best action?
Pause or modify the assessment based on patient tolerance
ASSESS FIRST if fatigue is impairing ABCs, if not, it is generally safe to "come back in 20 minutes"... (main idea, PRIORITIZE care)
A nurse observes pallor and diaphoresis but the patient says they feel fine. The nurse should:
A. Ignore objective findings since they stated "they feel fine"
B. Document both findings
C. Document patient statement of "no complaints" (since they feel fine)
D. Repeat assessment later
B (objective finding and subjective finding)
Why must the nurse explain the assessment process to the patient?
To reduce anxiety, promote cooperation, and build rapport
How should the chief complaint be recorded?
In the patient’s own words using quotation marks.
An unstable patient arrives with difficulty breathing. The nurse skips parts of the head-to-toe exam.
Question: Is this appropriate? Why?
Yes, prioritization based on patient condition (ABCs)
Which actions demonstrate clinical reasoning after assessment? (Select all that apply)
A. Listing abnormal findings
B. Identifying patterns
C. Creating a problem list
D. Documenting data only
E. Prioritizing patient issues
B, C, E
Give three factors that may alter the sequence of a head-to-toe assessment
patient condition
anxiety
loss of trust in health care professional
culture
LOC/instability
environment
communication ability
What are 3 consequences of poor documentation?
Potential legal liability, compromised patient care, miscommunication
the nursing student documented that they gave ".5 mL" of a medication. The RN knows that this documentation is part of the "do not use list"... WHY and HOW can the documentation be fixed?
.5 is not approved because the decimal can be missed, it may be interpreted as "5 mL". This can easily be fixed by documenting "0.5mL"
RN completed the entirety of the head-to-toe assessment and is about to leave. The patient was "chatty" earlier, but suddenly reports dizziness and becomes quiet. What action does not reflect correct clinical judgment?
A. Acknowledge that the patient is tired after the exam
B. Pause and reassess neurological status and VS
C. Document findings
D. Prioritize symptom investigation
A
What determines how a nurse conducts an assessment in a specific setting?
Patient needs, nurse ability, and facility policy.
explain why this is inappropriate documentation AND reword to be appropriate for documentation:
The patient is a rude 75 yo female, noncompliant with taking meds for 2 days
shows bias, judgement
potential rewrite: patient is a 75yo female who states "I have not taken my medication in two days"
the patient is clearly upset and adamantly refuses part of the assessment, even after being educated on why the assessment is important. What is the most appropriate next move by the nurse?
document "patient refused assessment of X" and follow up with any patient statement and education you provided
Which documentation entries meet all standards of accuracy, objectivity, and clarity? (Select all that apply)
A. Patient appears anxious
B. Patient pacing, wringing hands, states “I feel nervous”
C. VS stable
D. Patient noncompliant with medications
E. Patient refused morning medication
F. BP 86/54 mmHg, HR 118 bpm
B E F