Physical Assessments: Do Any Nurses Do Them

[romie]

It has become apparent to me early in my nursing career that many RNs are no longer performing thorough PA at the beginning of the hand off of care. Not one single nurse during my orientation as a new grad had a stethascope around their neck to ausculate lung, heart, bowel sounds. Not a single RN palapated a patient's abdomen or pedal pulses. When I started at a a new hospital as a new grad, my preceptor said to me as she observed me assess a patient "wow, that was a good and thorough physical assessment." I'm thinking to myself, this is what I was taught to do as a basic skill during my nursing school days at UIC.

I work on a tele unit and I am one of the few RNs who actually have a stethascope and calipers. Am I missing something? I know how important it is for a s/p lap cholect. patient to have bowel sounds but how can you assess bowel sounds if you don't have a stethascope. Asking a patient if they have passed gas is subjective. I need hard data.

So my question is, am I wasting my time physically assessing my patients? Granted I do a focused assessment based on their accuity and needs, but I will still inspect the feet of all my patients. Am I doing something wrong? Do I need to reprioritize? I really need some help here because I'm a little confused after all of the time spent at UIC on physical assessment. I don't want to falsify documentation when the computer prompts me if I heard bowel sounds or not.......

[Daytonite, BSN, RN]

so my question is, am i wasting my time physically assessing my patients?

we can only be responsible for our own actions. what would your nursing instructors have told you? do what you know is the right thing to do.

am i doing something wrong?

no. in fact, you are doing everything correctly.

suggestion. . .(1) check the policy and procedure manual. see what the documentation guidelines are for your facility. they have them because it is actually a jcaho requirement that each patient be assessed and it can be found in the jcaho accreditation manual for hospitals in the section for provision of care, treatment, and services:

standard pc.2.130

- initial assessments are performed as defined by the hospital.

elements of performance for pc.2.130:

1. each patient is assessed per hospital policy.
   
   
2. each patient's initial assessment is conducted within the time frame specified by the needs of the patient, hospital policy, and law and regulation.
   
   
3. a registered nurse assesses the patient's need for nursing care in all settings, as required by law, regulation, or hospital policy.
   
   

standard pc.2.15

0 - patients are reassessed as needed.

the scope and intensity of any further assessments are based on the patient's diagnosis; the setting; the patient's desire for care, treatment, and services; and the patient's response to any previous care, treatment, and services.

each patient may be reassessed for many reasons including the following:

• to evaluate his or her response to care, treatment, and services
  
  
• to respond to a significant change in status and/or diagnosis or condition
  
  
• to satisfy legal or regulatory requirements
  
  
• to meet time intervals specified by the hospital
  
  
• to meet time intervals determined by the course of the care, treatment, and services for the patient
  
  

element of performance for pc.2.150

1. each patient is reassessed as needed.
   
   

although the jcaho manual element of performance is continually saying: "each patient is reassessed as needed" that doesn't mean that the hospital nursing staff has carte blanche to determine when to assess patients. jcaho will expect that the nursing department will have policies and procedures directing nurses when assessments are to be done. (2) in some hospitals staff nurses are permitted to become members of a nursing council where these kinds of issues are addressed and managed and you can still maintain a staff nurse status. otherwise, consider working toward becoming a supervisor or manager so you can get involved in policy, procedure and enforcement and can do something about the people who are not doing things the way the facility policy and procedures say they should.

if you know others are falsifying their nursing documentation by recording assessments that they are not doing, that is a violation of the nursing law of just about every state. if you know that is happening, you need to report it to your manager. if the manager ignores you report it to the person who is the manager's boss and keep going up the chain of command until someone listens to you. in most places i worked falsification of the records was serious grounds for termination and when i was a manager we (the director of nursing and director of human resources) fired a nurse tech who was making up vital signs and blood sugars and posting them in the individual patient charts. we had another rn in a nursing home where i was a supervisor that was doing it with blood sugars and medications that she was charting and not doing, but she quickly packed up and quit when she realized she was being watched and evidence against her was being collected.

i am never pleased about managers that would hire new grads to work on a telemetry unit. that alone, i think, is indicative of poor judgment made by the person(s) who hired you. it tells me they don't care about the nurses. managers that will do this are usually only interested in filling holes in their work schedules. only experienced nurses should be hired to work on telemetry units. i worked on one for many years. i am not criticizing you. i think it's commendable that you are surviving there. i'm willing to bet that assessment problems are only the tip of the iceberg and that there are probably all kinds of policy and procedure violations going on.

[beachbutterfly]

Usually nurses dont have time to perform throughout assesement and it is then when 3 minute assesement technique comes in handy which focuses on asculating the lungs,heart and distant circulation (pedal pulses) Bowel sounds are important as well but obviously ABCs are the priority especially on tele..

[nitenurse02]

Nurses not doing assessments? That is scary. Nurses documenting assessments that were never done? Even scarier!!

I have a stethoscope but dont always wear it (being a LPN i dont always have a team of patients to assess). When I do have a team, I will do my assessments and then usually end up leaving my scope laying on a desk somewhere. But I have assessed my team first. I would not like being in your facility if you are the only one doing an assessment! Keep it up and dont let the other work ethic influence good patient care.

[NurseKatie08, MSN]

I've seen it too...on our computer system, you can see past treatment notes written by other nurses. I'll see people charting that an open area persists when it hasn't been an issue for days, or that someone's bilat breat folds remain pink/fungal when the area is resolved. I've also seen dressings I put on the previous evening on pts with BID dressing changes still on when I come in the next day.

It's scary...but all I can do is trust my own assessments and know that I'm doing my job...some people are just lazy.

I don't walk around with my steth on my neck typically (mostly bc having it flapping around irritates me), but it is always on my med cart, and it certainly is used!

[blondy2061h, MSN, RN]

I assess my patients every shift and I've never heard of a nurse who doesn't.

i don't carry calibers because I do measurements on rhythm strips on the computer, and just use lines on a piece of paper to measure if it's equal distance.

I don't carry a stethoscope because we have them in the patients' rooms.

[Indy, LPN, LVN]

To the OP: You just keep doing your thing, and you will get faster at it. I trained on tele, and we certainly were expected to know and chart lung and bowel sounds, peripheral pulses, etc. We were not expected to do much with heart sounds for charting, since there were multiple cardiologists making notes on these patients, but we did listen to the heart sounds and tell each other if there was something interesting to hear. Also for patients who had heart cath procedures, know if there is a thrill or bruit at the sheath site, make sure you catch pseudoaneurysms before they get to be a problem, and for dialysis patients know if the graft is functional or not, and that requires a steth for the bruit. So yeah. Got to get down in there and play with feet, groins, steth, etc.

Me and a classmate did seem to take forever when we got started on that as new grads. Boy oh boy so much to do, get the VS, etc. However we learned to prioritize and do it faster, and we didn't miss too much. Better to catch things and be a bit behind, than to miss something and have a code.

For prioritizing, by the way... I do stuff in rounds - best bit of advice I have EVER read on here btw. First, I see pts and make sure all are alive. Then sign all my papers (MAR, flowsheets) for the shift and see who's got VS due when. Then do beginning VS on all and focused physical assessment. Start med pass and if I missed anything on assessment, get it looked at on that round. See the tech and let her know whom I want to bathe and who I gotta do butt dressings on, etc. By the time meds are done, I probably have seen what I need to on everybody and have listened to what I need to... clean steth one more time and set it back in my bag. I don't like to have it on while bathing and doing dressings on people.

When I was on tele, I kept steth on me almost the whole shift d/t lots of changes in people's pulses, responses, etc. that required me to have it handy more often in the shift. So I guess it depends on where you work, and what the nurses routines have evolved to be.

[Batman24]

We all do them where I work.

[PostOpPrincess, BSN, RN]

Seriously? No assessment? I don't know--I've done them and continue to do them.

I don't know how one can be a thorough nurse without doing them.

No..I do know. You can't be a thorough nurse UNLESS you do them.

[DG5]

I don't quite agree with darkangel 05b's comments that a "lot of the older nurses seem to get lazy in their ways" - a rather sweeping comment.I don't think doing assessments thoroughly is related to the length of time you have been a nurse- it is related to the commitment one has to your nursing standards and this is something that is carried right through from the time you get out of nursing school to the time you retire as an RN.

[86toronado, BSN, RN]

Where I'm working my preceptor is thorough with assessments, but when charting on a vented patient the other day, I looked back at the day before, and saw that the nurse who had him had charted "clear" for all lung sounds, except where is chest tube was... and the man had rhonchi in all lobes! This was not a new problem, because although he hadn't been my patient the day before that, I had listened to his lungs, because of the chest tube... I'm just glad I'm precepting with a nurse who cares enough to show me the right way!

[ChristyRN2009]

I work on a stepdown unit and we do them q4h. No matter what. There are times when I see something that wasn't given to me in report and hasn't been charted on. But I just chart it, pass it on in report and try not to assume the worst. Case in point, I recently had a patient that I charted 0 edema all day, gave shift report and went home. I came back in and the offgoing nurse mentioned that the pt had gross pedal edema. I said he didn't have it on my shift, don't know what happened. Well lo and behold, the patient didn't have edema when I went in to assess him any of the times, but after he had sat up for an hour prior to shift change, he had edema. So it wasn't that I missed it, kwim even though it could be assumed that I did based on my charting etc.

So I say all that just to let you know, don't assume that someone didn't look at the patient all day, just make sure YOU do a thorough assessment, chart what you see/hear, and worry about what YOU can do for the patient on your shift. And if you really notice that NONE of the nurses do assessments (seems unlikely on a tele unit) then run, something very off about that facility that NO ONE seems to care.

[romie]

I want to thank everyone for their insight. As an RN with a year's experience, I will continue with my good habits: Head to toe assessments, checking iv access and IV fluids (I have found a few mistakes there. Luckily the patient outcome wasn't negative) and I would hope the nurse following me would do the same to catch anything I didn't see. PA's are a great way to spend some time with patients and develop rapport--plus I am such a worry wort that I can't comfortably go back to the nursing station unless I know everyone is okay. Not only does a good PA an imperative, but it makes us look good and makes the patient feel like they are "getting their money's worth".

I was shocked when I auscultated a patient's heart valves and heard a disryhthmia. I checked the chart and every nurse before me charted "regular". I asked another nurse to confirm and he said "yep, its irregular, lets call the MD." On the same unit during my orientation, I volunteered to do all the assessments on an assignment. It took me at least 45 minutes to complete my assessments. When I got to the paper chart to document, it was already done by another nurse! I had a another nurse yell at me during orientation and say, don't touch my patients, when I charted that I was unable to auscultate a psychotic patient's lungs, heart, etc. because she wouldn't let me near her. This nurse had charted that she heard her lung sounds. Please, this patient's mental illness is so acute, her paranoia so great that noone could even touch her.

Again, thanks for your support. and thanks for reassuring me not to assume the worst. I just want what is best for my patients.