In our haste we may inadvertently run through an assessment using the diagnosis as our primary focus. We can assume that this patient is being referred only for the diagnosis or problem i.e. poor feeding.
When we arrive to the bedside with that diagnosis or problem in the front of our minds it’s easy to overlook the baby as a whole.
We may assume that since others have seen this infant before us, and she had a Ballard Exam and a full assessment upon admission, that all other systems must be relatively ok.
But have you always found that to be true?
Of course not.
There are times (when we’re truly present to the assessment) that we find other subtle and important details. We may find a mild brachial plexus injury, a cleft in the soft palate, or a significant head preference. You get the idea. You’ve been there.
But observing these less than glaring problems takes presence, skill, patience and knowledge.
It takes becoming a blank slate when you begin your assessment.
Becoming a blank slate doesn’t mean you approach the assessment without any knowledge or consideration of what you’ve read in the chart or learned from the other staff. It means that you don’t pre-decide what you’re going to find when you do your assessment.
When we pre-decide the problem, presentation and solution before ever observing and assessing the infant, we’ve lost something. A piece of our value and excellence is left unused.
Remember that no one else sees and assesses infants through the same lens that we do. We bring a unique set of skills and knowledge to the table (or incubator as the case may be).
Honor what you know. Ask questions about what you don’t know. Learn all you can from the chart and other staff and then become a blank slate.
The infant’s body and system tells a story.
Your best work is knowing how to listen.
