Shift assessment... really? - page 2

I was auscultating a pt's abdomen last week during a shift assessment when the patient said "you're the only person who's done that since I was admitted". I was surprised. So, I started thinking... maybe I'm going overboard... Read More

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    Quote from nursingpower
    Cardiac ICU with 2.5yrs experience out of nursing school: I do a head to toe every patient every shift. I look at med drips, every line in and out. Check my piggyback infusion make sure bag is before pump. I've gotten better at clumping all my questions together in a casual convo: Introduction, check ID band/patient's orientation. pain, cough, swallow well, belly tenderness. Then I listen: Heart, lungs (A/P all the time), belly. Then I palpate, belly, pulses. Then I test strength. Draw labs if needed. This process takes me about 10 minutes each patient.
    That sounds quite reasonable. It's a well-organized method of assessing and including all the vital information you need on your patient.

    Quote from nursingpower
    I feel like I am always doing something. I rarely sit for more than 15minutes each hour it seems. I see my fellow nurses reading books, playing internet games, gossiping, studying, etc. I'm like wow, I never have time to do those things. Wondering what am I doing wrong. Is it my assignment? Do I spend too much time with my patients? Am I doing things that I really don't have to do?
    Most of the time I don't sit much either, and I've been doing this job for 14 years. If I'm not busy with my own assignment I'm usually helping somebody else. But it is possible that you're doing things you don't really have to do. That sets you apart from the others.

    Quote from nursingpower
    I have seen nurses that come in and before they look at their patient do all of their computer charting. I asked one person how, he said if there are any changes he go back in later and change it but he wants to get all his computer work out of the way.
    What do you think risk management and legal would have to say about that? It's certainly not how it's supposed to be done, and they could lose their license for it. Imagine if the chart ever went to court and the patient or a family member testifies that at NO time during the shift did the nurse ever touch the patient, and yet all the necessary charting has been done. Major trouble! This is one habit you do NOT want to incorporate into your practice!!!!!!!

    Quote from nursingpower
    It's nice to have these kinds of nurses available because they are always available to help others i suppose. If a code happened they are ready to go.
    I find that these sort are the ones that are oblivious to what's going on around them and are actually of little help.

    Quote from nursingpower
    My supervisors have praised me on my thorough charting. I've also had patients tell me that I am very thorough to the point where one patient asked me if I had to do all that I was during my assessment. He said, "You are the only nurse here that did all of this". I told him we have to chart and I don't want to lie and say lungs clear, skin is fine, no air leaks in chest tube, Alert and oriented, etc when I don't have a clue. I can't lie like that so I am forced to check because I am legally bound by my assessment. He said, "OK, well I'm not trying to give you a hard time, guess you gotta do your job".
    Thorough charting is fine, excessive charting not so much. Be sure that you're only charting factual, objective information. As for assessments, there are some things you can assess without actually "assessing" them. If I've seen a patient open his eyes, swallow, cough, shift position, raise a hand or foot off the bed or grasp their ETT and let go when I tell him to, then I'm NOT going to go over and say, "Okay, Bob, let's check your neurovitals. Can you open your eyes for me? How about squeezing my fingers?" After your initial head-to-toe assessment you should be doing intermittent focused assessments and charting changes.

    Quote from nursingpower
    I am still trying to figure out ways to shorten my shift but still do what is required of me. Sometimes i want to sit down and do nothing for an hour.
    Don't we all? Most of it comes with time.
    suzi_Q, maelstrom143, flyingchange, and 2 others like this.

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  2. 0
    I'm a new nurse, and I do a quick head-to-toe on every patient for the initial assessment and focused thereafter.

    If someone has been up and about, the neuro, skin, musculoskeletal, and GI assessment is very, very quick. I'll talk to them to determine A/O, and if they are A/O x 4, I'll ask them about weakness, skin problems, pain, BMs, nausea, overall "feeling" while I'm listening to lungs, heart (also checking lead placement and adherence), checking abdomen, and checking for extremity edema and doing IV site assessment. For these people, I also ask if any abnormal is new or something that they just live with, e.g. old fractures that didn't look as if they were set right. (Had one patient the other day with that; cool story to go with it, too!) If they have a s/l (no fluids running), I'll flush to determine patency.

    Bedfast or A/O x 2-3 or forgetful patients take more time, but I still do everything (with a careful skin inspection--those that can pull themselves over with the handrails I do by myself; others, I get help from the CNA) and note their positions. I jot down R, L, or S (for supine) and the time. Two hours later, if they are still in the same position, I reposition them and jot the new position.

    It takes time, but it's my job. I feel comfortable with my assessment routine and my charting of it. It's what to do with the acute changes is where the real nursing comes in, and, of course, as a new nurse, I seek support when necessary and debrief with the experienced nurse so that I can apply the info in the future.
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    Yea, I am still new, but I chart everything when I do my assessment. If they got a bruise I chart it, If they have excessively dry skin that is flaking or no great toe toenail it gets charted. My assessments usually take like 10 minutes or so. I like to talk to the patient and family and answer questions if they have any. Also give them a heads up on what to expect on my shift (VS q 4, walking, etc...).

    But I am still new and still very cautious
    mjs488 likes this.
  4. 1
    My head to toe usually takes about 5 min. The walkie/talkies are the easiest as they can answer questions while moving extremities, repositioning, etc. The total cares may take a bit more time (if too large to move alone, I keep an eye out for the CNA so I can help clean/change the patient and do the back skin assessment at the same time, ideally at the start of the shift, but no later than 10 am).
    Neuro's can be checked on the fly w/some patients. Ask re: dents, glasses, hearing can usually tell the HOH. You may see glasses at bedside. Ask them to stick their tongue out at ya and then raise tongue to see any skin breakdown/ulcerations/thrush and neuro function (i.e. deviation). Palpate chest for ports, aicd's, listen to sounds (heart, lungs, abd), raise gown to see abd, groin (recent cath's?), any rashes/bruising/ostomies/fc/etc. Ask re: LBM and voiding (any difficulty? enlarged prostate?) as you review abd region. Look at arms, IV sites. Go down legs (edema/cool/warm/etc.), check pedal pulses, missing digits/nails. As you are working your way down you should be able to visualize any skin/bone abnormalities. Then ask patient to roll over and listen/look at back/buttocks. IV sites and IVF checked for patency and accuracy (have had a few have the wrong fluids/no fluids running when orders specified otherwise).
    To me, a good initial assessment makes your shift easier in the long run. We have to assess our patients every 4h, so knowing what I am looking at really helps me when any changes take place. My assessment also usually tells me when things have been overlooked and need to be addressed (i.e. new iv sites, no bm x4 days, urine output inadequate or urgency/burning/pain/difficulty voiding, thrush noted on tongue, new skin breakdown or tears).
    mjs488 likes this.

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