Assessments every shift?

Nurses General Nursing

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So, I'm about to get out in the real world of nursing. I worked as a tech for awhile on a busy med/surg unit so I feel like I have a little real world experience that will come in handy. I realize that not everything you learn in school is practical in practice, but I have a concern about the lack of physical assessments I've witnessed (or failed to witness) by the nurses.

Of course, they tell us in school that we're to do a full physical assessment on each patient at the beginning of our shift. That would include listening to heart/lungs, checking the skin, pupils, etc.

The only time I ever see a full physical assessment is upon admission. I'm wondering, do the nurses just trust that the nurse who admitted the patient documented everything accurately and go by that? What if the patient had a pressure ulcer or something and the admitting nurse didn't see it, or actually didn't even look?

I'd like to do full physical assessments on all my patients, but I am naive to think that's possible? Do you do them each shift? I know that a lot of times you can assess a patient without being obvious so just because I might not see the nurse take off the patient's socks and feel their pedal pulses doesn't mean they didn't do it. However, I have seen patients come in wearing blue jeans and never take their jeans off when the shift changes. So, I KNOW they didn't even glance at the patient's back side, etc.

What do you do?

I always do a head to toe assessment. I'm a float nurse so I never trust what someone else documented. I've have found wounds that weren't documented, someone is hard of hearing and that wasn't documented, a pacemaker that wasn't documented, ports that weren't documented. And more often than not no assessments at all! You name it I have found it. So I didn't read all the responses yet but yes do a head to toe assessment on all your patients. The more you do it the less time it takes. I start assessing the moment I walk in a room. I flip them over real fast listen to lungs glance at their bottom. Feel pulses I left up their legs slightly to see if they have breakdown on their heels especially my total care patients. I automatically go in turning them and when I do I can get a good look at their skin.

So this is harsh but don't worry about what other nurses do. You do what is right and document everything you see and do.

And something else I always find strange. How can you do an assessment and I never once see you with a stethoscope? I see this ALL the time when I work. And I know for a fact that there aren't any in the rooms. So carry one and assess away OP.

Specializes in ORTHOPAEDICS-CERTIFIED SINCE 89.

Most of the above is why I stay with my family member when they are in the hospital. For example my husband calls me saying his IV is beeping and his hand is swolen, I hear him notify the station on the call system. I dressed and drove an hour to the hospital, found a parking space, walked to the furthest floor and the furthest nursing unit and when I walked in the IV is still beeping and his hand is softball size. Hmmmm. And yes I did what you think I did. Silent and deradly is my manner. Band aid, Ice in glove and nurse call in that order.

Then after the fact the Supervisor and the VP for Nursing showed up and asked what was the problem. I carry a digital camera, I showed them. I have 38 years as an RN. But I guarantee I never let this happen to a patient. I also neve let it be known I am a Nurse. My husband was alert, oriented in spite of his age (70) he is definitely NOT senile.

I will say the last night I worked I had 15 patients on an acute Ortho floor, and that is a LOT of patients! You still have to assess every shift.

A lot of us older RNs can assess in ways you are not yet aware of. Hopefully, body sounds are listened to! When I first became an RN I thank my stethoscope for identifying a AAA. I am just hoping the RNs you work with are doing this austere assessment method rather than not assessing. As previously said, you are the only one responsible for your patients on your shift. It doesn't matter what anyone else is doing. You have to do things the right way.

When you start finding a lot of things that have gone uncharted previously, then you will be entering lots of RDE's in the quality dept. If your unit is doing things right, they will be following up on these issues and you will hear announcements over time that "assessments must be thorough and complete"....etc. If you are not called in to follow up on the RDE's that you enter, you can be assured your hospital or unit is lacking in quality control and you can either call the quality hotline annonymously, or go straight to your manager. If your manager still is non-responsive, then you can arrange a meeting with the DON. You can push this as far as you want, be a rabble rouser for the sake of the patients.

But bottom line is that you assess top to bottom. Although I don't know if the rectal exam is really necessary unless your gut tells you so. It really is our duty to fill out those RDE's so the hospital knows what needs improvement. Remember, filling out the RDE's isnt like 'writting someone up'...it is mearly a head's up to administration that current practices are innefective and need to be changed.

As a RN, it is your job to assess, it is the first step of nursing (ADPIE) and it would be neglectful to not do it. As everyone else has said, some nurses just chart what other assessments have said without having assessed the pt themselves. I have walked in and IVs are not there anymore when you need them...it is always good to look at your patient and know what you are in for to set up your day. It is also useful to assess, and see if anything has changed since their last assessment, because you should be reporting significant changes. As for people that can get oob and walk around, skin usually isnt an issue...you dont have to check their backs or bottoms unless they complain about something. If they are nonverbal, somnolent most of the time and havent ben out of bed in days, then yes check their skin thoroughly. Usually you would not do a pupil/neuro check on a pt unless you are on a stroke unit and sometimes it is ordered q4, q6 etc. on med/surg floors. I always check lung sounds, heart, pulses, bowel sounds, look at the legs/ankles for edema and feel for pedal pulses at the very least. Check their IV site ask if it is causing any discomfort, make sure their 02 is at ordered rate, ask about BM,urination, pain. It usually takes less than 5 minutes and there is no excuse not to do it. Many people are not getting better day by day they could be getting worse and how would you know if you didnt assess?

Specializes in ER, progressive care.

Always do your own assessments and don't trust the nurse before you. I always look at pupils/assess (and continue to especially if the patient is a neuro patient), listen to heart/lungs/abdomen, palpate abdomen, ask about their bowel habits/urination, then assess their lower extremities for edema/pulses. I also ask about pain. Check your IV fluids and make sure the correct bag is hanging (I had a transfer and the nurse before me didn't scan in the medication and therefore had a bag of LR hanging instead of the ordered NS :wideyed:) and make sure it is going at the correct rate. Look at your IV site. If the patient is supposed to be on O2, make sure the they are wearing it for one and make sure it is at the correct flow. If the patient has any tubes, look at these as well. If they have an NG tube, look at the drainage and if suction is ordered, make sure it is going at the prescribed rate. If a patient has a chest tube, make sure the amount of suction is at the prescribed rate, look for air leaks, palpate for any subcutaneous air, etc.

As Esme stated, your assessments can be staggered throughout the shift. If a patient has a dressing that is clean, dry & intact but drains a lot, I will change it once the dressing becomes dirty. Or if I know I have a scheduled dressing change later in the shift, I will assess the wound once I do that dressing change, not at the start of my shift.

Specializes in Med/surg, Quality & Risk.
Never trust the previous shift's assessment. True story... I received report on a patient who the reporting nurse said had + pedal pulses bilat. Imagine my surprise during my assessment when I pulled back the bed covers and saw that he had bilat BKA's. The moral of the story? Do your own assessment!

I have had two patients that had lung resections where nurses for 2 shifts before me charted CTA bilaterally!!! I was like, "Um have you had a lung surgery? Otherwise we need to talk" lol

Specializes in ICU.

Right now I work in med-surg. After being an RN for 23 years, I can do an assessment pretty quickly. I always look at my patients at the beginning of my shift; if I don't know what they looked like "before," how will I know if something has changed?

I am a CNA in LTC and in nursing school. I have had many nurses ask me to look at a patient's backside and report any issues when I go to change/bathe them. I have also had nurses tell me to notify them when I go to change/bathe a pt. and they will go in and help me so they can look themselves. Many nurses will rely on the CNA's to report this to them and then they can come assess. I know CNA's can't assess but if there is a skin integrity issue it's the CNA's job to report that too.

Specializes in Cath Lab & Interventional Radiology.

In progressive care we do assessments Q4H. Yes, we wake the patient every four hours to do a head to toe assessment. Sometimes certain assessments are every hour or even every 15 minutes (like when a femoral sheath is in place). I never skip these as they are to be done for a reason. At my facility we check all lines, tubes, drains, wounds, and dressings during bedside report. This really ensures everyone is on the same page and that report was accurate.

When I was in the hospital for my cervical spine surgery I was never assessed at shift changes. I even had one snotty CNA tell me she was "surprised" I was in for an extra day because I was doing so well. The night nurse before her shift never came in at all to look at me until the xray tech returned me at 4 in the morning. Then she takes a look at my foley and the urine bag and says "oh, I better empty this!" That was over 12 hours after my admission to the floor. She had no time for me but I hear her saying she felt like she was neglecting me outside my room and then run off to the nurses station to chat about her weekend.

When my Neurosurgeons PA came in the next morning she was visibly upset that I hadn't been ambulated yet and my foley hadn't been removed. That was over 17 hours since my admission to the floor.

After reading some of the comments on this thread I know none of you work at the hospital where I had my surgery. You all are very conscientious about your work and seem to care about the patients.

Specializes in PACU, pre/postoperative, ortho.
do the nurses just trust that the nurse who admitted the patient documented everything accurately and go by that?

As everyone above has commented, the answer is clearly no. Even if you know the previous nurse very well & trust their judgment, a lot can change from one shift to the next.

For me, working on nights, I make it a point to do my full assessment all at one time in order to disturb the pt as little as possible through the night. The skin check is often best done at times when a pt needs cleaned up or is getting up to the commode, etc. Those at risk for skin breakdown, get a better skin check than a lot of other pts I have who are coming in for elective ortho procedures.

Sometimes, since my shift is a little less hectic than previous shifts, there are things that I find from being able to spend a little extra time that go unnoticed by the earlier shifts. Also on those skin checks, even when multiple problems are passed on to you in report, don't expect that is the full picture. Just a few days ago on a new evening admit, I was told in report that there was a decub on the right heel; doc was called, orders received, etc. Well, I assessed the new dressing & then looked at the left heel. Guess what? A very nice unstageable ulceration to that heel as well which was completely missed. (How???!!) And don't forget your facility will get hit with the cost of tx if these are not documented (I believe within 24 hrs of admission).

You must do your own assessments every time.

Specializes in LTC, med/surg, hospice.

Do your assessment and chart carefully. Lung sounds change, edema changes, etc. You must have a baseline for your patient during your shift.

I have had a patient that a wound location was charted wrong for 3 days...I was told correctly in bedside report but the wrong box was clicked and each nurse after kept clicking.

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