Patient Assessment Q&A with the Clinical Team

Do we have a guide standard practical method to do that (Patient Assessment) or a senior nurse who will return demo that to a patient in front of us?

The head-to-toe assessment template provided by the Health Carousel Clinical Team is a great resource to use to develop your assessment foundation. When you start your assignment in the US, your facility will assign you a preceptor who will help coach, educate, and guide you through your transition to US nursing practice. Your preceptor will be your go to source of information and resources with your onsite clinical instruction. It is best practice to be confident in the questions you have and your ability to find your voice. If you need help navigating a head-to-toe assessment, it would be good to ask your clinical preceptor to provide a demonstration, followed by a repeat demonstration performed by you, with the ability of your preceptor to correct and coach you. If you have ongoing clinical questions about assessing specific body systems, you can reach out to your Clinical Support Nurse with Health Carousel or take advantage of your free education resources in your Health Carousel HealthStream account.

Can we use this Head-to-Toe assessment template in all hospital or it depends on the hospital policy?

You may use the Head-to-Toe assessment outline as a checklist at first if you wish. Through repetition and experience, you won't need a checklist as this skill will quickly become muscle memory! Keep in mind, each specialty will have its own focus in the assessment. For example, a Mother-Baby RN often checks the mother's fundus and lochia. A nurse on a Med/Surg Oncology unit wouldn't have that as part of their assessment. This template is meant to be a GENERAL guide for what is expected in a Head-to-Toe assessment on a patient and a basic nursing skill that is expected to be mastered here in the US.

How many times are in-patients assessed in US Hospitals per shift?

Typically the frequency of assessments performed in the hospital has some variance depending on the nursing specialty. But as a general rule, here is a typical assessment schedule that you will find in the hospital setting. Upon Admission – A comprehensive assessment is performed, including medical history, vital signs, and physical examination (the Head-to-Toe). There are also routine assessments that are performed throughout a shift– Most hospitals follow a schedule, such as:

• Every shift (every 8-12 hours) – Nurses perform assessments at the start of each shift.
• Every 4-8 hours – For stable patients, assessments may be done at these intervals.
• More frequently (hourly or continuous monitoring) – For critically ill patients, such as those in the ICU.

Vital Signs Monitoring – Typically done every 4-6 hours for stable patients, but more frequently for unstable or post-operative patients.

Special Assessments – Some conditions require additional checks, such as neurological exams every hour for brain injury patients. (Example: a stroke patient)

Ultimately, assessment frequency is based on hospital protocols, the patient’s diagnosis, and their response to treatment.

Is the medication signing in the US done through the computer system?

The process of administering and documenting medication administration in the US will follow these steps.

1. Prepare the Medication

• Step 1: Retrieve the medication from the appropriate source (e.g., medication cart, Pyxis machine, or pharmacy).
• Step 2: Check the medication against the order to confirm that it’s the correct drug, dose, route, and time
• Step 3: Ensure that the medication is correctly prepared and ready for administration (e.g., drawing up injectable meds, setting up an IV infusion, or organizing oral meds).

2. Scan the Medication and Patient's Wristband

• Step 1: Scan the Medication:
  
   
  • Use the handheld barcode scanner or the Epic mobile device to scan the barcode on the medication’s packaging or label.
   
  • Epic will compare the scanned medication’s details (name, dose, and lot number) against the physician’s order in the EMR.
   
  • If there is a discrepancy (wrong medication, dose, or timing), Epic will alert you, and you will need to correct the error before proceeding.
 
• Step 2: Scan the Patient's Wristband:
  
   
  • Scan the barcode on the patient's wristband. This step is crucial to ensure you are administering the medication to the correct patient.
   
  • Verbally ask the patient/family member to state the patients name and Date of birth.
   
  • Epic will compare the patient’s identification information with the medication order and alert you if there’s a mismatch.

3. Verify the Medication and Patient Details

• Step 1: After scanning, Epic will display a prompt or summary that shows the medication you’ve scanned along with the patient’s details (name, medical record number, etc.).
• Step 2: Verify that the details match the medication order, ensuring you have the right drug, dosage, and timing.
• Step 3: If everything is correct, confirm the information in Epic to proceed with the documentation. If there is an error, Epic will notify you, and you’ll need to resolve the issue before continuing.

4. Administer the Medication

• Step 1: Administer the medication to the patient following the correct procedure (oral, IV, injection, etc.).
• Step 2: Ensure that the patient is monitored for any immediate side effects or reactions after medication administration.

5. Document the Medication in Epic

• Step 1: Once the medication has been administered, return to the Epic system to document the medication administration.
• Step 2: Epic should automatically populate fields based on the medication order, such as the medication name, dose, and time of administration.
• Step 3: You may need to enter additional information such as:
   
  • The route of administration (e.g., oral, intravenous).
   
  • The site of administration (if applicable, e.g., IV site, injection site).
   
  • Any additional notes regarding the administration (e.g., patient response, problems, or issues encountered).
 
• Step 4: If you encounter any issues or need to make a note of the patient’s response to the medication, document this information in the appropriate fields (e.g., adverse reactions or patient condition post-medication).

6. Review the Medication Administration Record(MAR)

• Step 1: Once documented, review the Medication Administration Record (MAR) in Epic to ensure everything is accurate.
• Step 2: If any changes or updates are needed after reviewing the MAR (such as documenting a side effect or a missed dose), make sure they are properly noted.

7. Sign or Complete the Documentation

• Step 1: After entering all required information and verifying its accuracy, sign or finalize the documentation in Epic.
• Step 2: Epic may prompt you to sign off on the medication administration to confirm that it has been completed and documented correctly.

8. Follow Up and Monitor

• Step 1: Ensure that any necessary follow-up actions are documented, such as scheduling the next dose or reporting adverse reactions.
• Step 2: Monitor the patient as needed for any side effects or issues related to the medication and document any updates in the patient’s record in Epic.