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... Read More
1Nov 29, '11 by maelstrom143, ASN, RNMy 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 aids...you 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).