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.......

[DeepFriedRN]

I hate it when I see nurses who I KNOW haven't even been in a room, much less assessed their pts, completing their charting an hour or so after the starrt of shift. I'm not a stay late every shift person or anything, but it's totally possible to do a basic head to toe assessment in approximately five mins or so.

I am pathologically honest, and I just could not bring myself to chart on something I haven't done. I'd feel awful, besides the fact that it's legally and ethically wrong. I always wonder how those nurses feel when their pt goes bad after they charted they were fine without really checking them out. And I really hate the fact that when I do chart say, rhonchi, and then see the last 3 shifts have charted clear, that I sometimes feel I have to second guess and wonder, did I really hear that? Or did they not really listen? Or is it new? Most of the nurses I work with I trust implicitly, and so I know it's probably a change in condition, but there are those few that make me wonder..And that sucks.

[FranEMTnurse, CNA, LPN, EMT-I]

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.

this happened to me in 2006. firstly, due to a lack of proper communication between staff, the reason i was not able to raise my head was because i emitted 6 pints of systemic blood about a week earlier. the people taking my bp never communicated or looked up in my chart my normal bp, and assumed mine was always low. not!!! i take medication for hypertension.

secondly, after i was diagnosed with pulmonary hypertension, i was moved immediately into the telemetry unit. that night, i suffered hypoxemia, and went into a panic attack. nobody knew what to do. my friend who was a private practice hospice nurse at the time, phoned me, heard how i was, and immediately got in touch with my pcp. ativan was ordered immediately. i will always be thankful for her action. at the time i thought i was smothering to death.

the third dangerous thing that happened the day after i was admitted to that unit. a cheerful aide who said she was from the islands, raised the head of my bed in the high trendelenburg position, and i went into kidney failure. she cried, and that made me feel bad for her. i knew she didn't do that intentionally, but she was unknowingly killing me. it doesn't pay to take things for granted.

after that, a new graduate nurse was assigned to me. i asked her to please close the curtain so i could sleep since the cieling light was shining directly into my eyes. she said she couldn't do that, because she had to monitor me. the monitoring unit was across the hall from me. i could see it from my bed. what was wrong with reading my rhythm? couldn't she tell by that if something was going wrong?

next occurence, i met the very loud don in that unit earlier that evening. she was big and burly. i recognized her face, and told her i had seen her before, and asked her what her name was. she told me her name was mud. very unfriendly type for sure. anyway, an 8yo accident victim arrived later that shift. that nurse monitored the boy until he expired. i heard her pronounce him, tell the staff to go get the gurney to take him to the morgue, and i saw the very familiar banquet table shroud on the gurney, and knew they were taking the child down to the morgue.

i was forced to be hospitalized for 2 weeks, but was so traumatized by those experiences that after being discharged, i asked my doctor to put me in hospice. i didn't want to darken the doors of our local hospital ever again. i was in hospice care for a few weeks, but began to slowly improve.

some time had passed, and i began to change my mind about being in hospice so i informed my doctor i wanted to go off of it since i was improving. as you can see i'm still around.

[Sunflowerinsc, ADN, RN]

I am one of those" older nurses", and I do an assesmant of each pt that I care for every day. It may not be in the first 15 mins after report, but it does get done. I have learned to determine which pt needs my attenetion first. If not right away then with my first med pass. I will admit that I didn't learn these skills in nsg school nessecarily, but have picked up these skills as the role of the nurse has changed in my career. i too, often have pts or family members say to me what are you doing, I have never had a nurse do this before.

I also am a "older nurse" , well really old! I do an assessment on all my pt's every shift. I might not get them all done as soon as I come on but I sure do before I chart anything. I see everyone as soon as I get report, make sure they are breathing and not in pain and IV site is ok and NPO pt's know they can't eat. Then meds, insulin ,ect and then am able to finish a complete assessment. Not only heart, lungs, abd, ect also skin check . No way chart anything thing without seeing and hearing. There is no telling what you are going to find!

I have worked with new and old nurses who seem to get done really fast but that nearly always comes back to get them. Like others have said lungs charted as clear and Dr. comes in and pt in CHF, ect.

So keep up the good work for your safety and your patients

[lauramae18]

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.

I don't want to derail this thread... but I have a few questions for you:

What unit would you recommend new grads start on? How do nurses learn to be adequate to work on a telemetry floor? Does this also mean that new grads shouldn't work ICU's?

I ask because I work on a telemetry floor and started there directly out of nursing school. I had an awesome preceptor and a great bunch of people to use as secondary resources... which I still do because someone will always have more experience and knowledge than I do. I don't think my manager has poor judgement in hiring new grads; she has a good eye for taking GN's who have potential and are good fits for our unit that turn into valued team members who are resources for the next new batch of nurses. I think every type of unit/ application within nursing has pros and cons for hiring/not hiring new nurses, but we all need to start somewhere.

[Wishinonastar, BSN]

Wow great topic! Remember, the bottom line is your care is your care. You are responsible for what you do regardless of what those around you do. In any area of nursing you will see nurses who don't care and do the bare minimum. When I was oriented to school nursing the school nurse I was with only checked temps, never lung sounds. We guess what, now when I work in the school I check lungs whenever I feel I need to. If they sound like crap I don't worry so much about the fever. You have to be able to breathe to function. It is my nursing practice and I will stand by my practice. What she does is up to her.

You go girl, use your skills, do your thing. Calipers, I would live without, but my stethescope is my lifeline and I won't even use another one unless I have to for some reason. It stays with me wherever I work and I don't care what anyone thinks or says.

[Wishinonastar, BSN]

I don't want to derail this thread... but I have a few questions for you:

What unit would you recommend new grads start on? How do nurses learn to be adequate to work on a telemetry floor? Does this also mean that new grads shouldn't work ICU's?

I ask because I work on a telemetry floor and started there directly out of nursing school. I had an awesome preceptor and a great bunch of people to use as secondary resources... which I still do because someone will always have more experience and knowledge than I do. I don't think my manager has poor judgement in hiring new grads; she has a good eye for taking GN's who have potential and are good fits for our unit that turn into valued team members who are resources for the next new batch of nurses. I think every type of unit/ application within nursing has pros and cons for hiring/not hiring new nurses, but we all need to start somewhere.

Oops, just saw your post too. I worked telemetry for a while, and we had better orientation and better staffing than the med-surg areas. I don't see a problem with a new grad on telemetry. Just my opinion, of course.

[paula53]

I am so happy that you are doing your PA. Please do not stop that practice because there are somany issuses that can be identified before they become an emergency by just doing a physical asssessment.

I do think that this is an issue that you should talk to the manager or take it up with the patient care counsil of your institution. I am sure that the patients are noticing that the nurses are not doing their assessment, or that it is being done inconsistently. I do sincerely hope that the nurses who are not doing their assessment will see how you practice and try to emulate it. Hopefully one day you will be a preceptor and will make sure that the nurses who you precept are doing their assessment.

Thank you for being an example.

[Shaka]

I am a long term nurse and have always done assessments. If I chart that I did one and didn't it is lying, number one, which is an integrity issue in my mind. I have to say that I don't wear a stethoscope around my neck. It gives me more stiffness in my neck and back which any given shift does on its own. I actually had my stethoscope stolen,a cheap one, so I use what the hospital has or borrow one. My area is OB and there is always a supply of them around.

The other frequent occurrence is not being able to do all of my assessments immediately after I get report. Again, if I have a problem.....orders to be completed, admissions or a crumping patient, I may not get to it until a couple of hours into a shift. The main thing is that I don't chart what I don't do and if I didn't do it, I don't chart it.

I recommend that you continue doing what you do, PA's. Never mind what others are doing, it is your face you look at in the mirror, expensive stethoscope or cheap one.

[SCgirl22]

I have definitely seen corners cut on my floor. I am one of the few nurses who carries a stethescope. I have always wondered how they know bowel sounds are present or lungs are clear/ diminished w/o auscultating them. Are they sticking their ears on all the patient's abdomens to listen for sounds? LOL...I think not!

I can't tell you how many times I get asked to "borrow" my stethescope for a minute...ticks me off b/c we should all have them and use them daily, not just when checking air boluses in NG tubes or when your patient's breathing is so bad you can hear the fluid/congestion in their lungs from the doorway! If folks were more diligent problems would be caught much sooner!

Take pride in your work and knowing you are doing the right thing for your patients. Your thoroughness will surely save a patient one day! And you can rest at night knowing your license is safe!

[CountyRat]

I will admit, though, if it's a patient I've had for a few days and it's an easy patient - in with chest pain and now it's changed to lytes imbalance, for instance, my assessment is a much quicker re-assessment.

That is nothing to feel bad about. Follow-up assessments should be brief and focused because you already have a lot of information about the patient from your initial assessment.

[kingsmiley]

actually it doesnt take that long to do a basic assessment. u r one of the good one, pls dont stop

[southernbeegirl, BSN, RN]

some of the nurses i work with never have a stethoscope with them ,ever. yet they chart apical pulses for dig and lopressor and not to mention the daily skilled assessment.

i cant do that. if i charted on them you bet your skippy i did the assessment. i keep imagining myself on the stand in court defending what im charting.