Physical assssments

Nurses General Nursing

Published

Hi,

I am giving a presentation this week and would love to add some comments from US nurses and nurses from overseas who are now working in the US.

How important is it to complete a head to toe assessment Q4 hrs - why do it, why not and whats your average time to complete. ICU nurses - how often do you complete them in the Unit?

History behind my question. I am a UK nurse who worked for more than 10 years in the US, and now that I am back in the UK, find it hard to understand why we do not do them here. Hence I am writing a refelctive essay on physical assessment, as well as giving a presentation.

Thanks

Specializes in CVICU.
Hi,

How important is it to complete a head to toe assessment Q4 hrs - why do it, why not and whats your average time to complete. ICU nurses - how often do you complete them in the Unit?

A complete head to to assessment is essential to understanding what's going on with your patient. I couldn't even imagine trying to treat my patient without doing one. For example, say the patient's BP is low and the doctor orders a fluid bolus. You may decide to tell him/her to consider something else if the patient's lungs have rales (possible fluid overload). This is just one example.

I work in the ICU, and we do assessments every 4 hours and more frequently depending upon the patient's condition. A fresh post-op heart patient will easily get one at least once an hour for the first 2-4 hours. It generally takes me about 15 minutes to do an assessment, but of course this depends on if the patient is awake, sedated, crazy, etc :chuckle

Specializes in Med/Surg, Geriatrics.

I don't believe a head to toe every 4 hours is necessary: once you do your initial you need only assess for changes and even then your assessment should be focused based on admitting diagnosis, current problems and new symptoms. A head-to-toe q4 hour assessment would not be economical time-wise and again, unnecessary.

Specializes in CVICU.
I don't believe a head to toe every 4 hours is necessary: once you do your initial you need only assess for changes and even then your assessment should be focused based on admitting diagnosis, current problems and new symptoms. A head-to-toe q4 hour assessment would not be economical time-wise and again, unnecessary.

Umm, how do you assess for changes if you don't do the entire assessment to see what has changed? :confused:

I guess this depends on where you work. This is expected in the ICU where the nurse typically has 2 patients. Anything can (and sometimes will) go wrong, and you never know what bizarre or potentially life-threatening change you will find with your next assessment.

i can see them being done q4h+ in icu, easily.

but pretty much, i think q shift would be sufficient...

unless you note an abnormality which warrants follow up.

leslie

Specializes in Med-Surg, Trauma, Ortho, Neuro, Cardiac.

In med-surg, once a shift is o.k. with focused assessments on areas of concern. For example if you came in to have your gall bladder removed, I'm not going to assess pupil reaction and my neuro exam would consist of noting if you're alert and oriented. I would focus in on your lungs, fluid status and abdomen the most.

Specializes in Cardiac Telemetry, ED.

Our policy is Q shift (we do 8 hour shifts). We call them "systems" assessments, as we assess each major system.

Specializes in Acute Care Cardiac, Education, Prof Practice.
In med-surg, once a shift is o.k. with focused assessments on areas of concern. For example if you came in to have your gall bladder removed, I'm not going to assess pupil reaction and my neuro exam would consist of noting if you're alert and oriented. I would focus in on your lungs, fluid status and abdomen the most.

:yeahthat:

I work on med-surg.

Tait

Specializes in Advanced Practice, surgery.
Hi,

I am giving a presentation this week and would love to add some comments from US nurses and nurses from overseas who are now working in the US.

How important is it to complete a head to toe assessment Q4 hrs - why do it, why not and whats your average time to complete. ICU nurses - how often do you complete them in the Unit?

History behind my question. I am a UK nurse who worked for more than 10 years in the US, and now that I am back in the UK, find it hard to understand why we do not do them here. Hence I am writing a refelctive essay on physical assessment, as well as giving a presentation.

Thanks

We do assess our patients in the UK but we do it differently to how it is done in the US. Are you telling me that as a qualified nurse in the UK you don't go and see every one of your pateints when you come on duty, and when you see that patient you don't look at the observations, talk to the patient, assess level of conciousness, pain assessment, in immobile patients check areas at risk of pressure damage, mucous membranes, etc etc

When i worked in ICU we did a full clinical assessment when coming on duty and then routinely during the shift, now I work on a surgical ward, no I don't do a full clinical examination on every patient but I do a nursing assessment, I don't listen to the heart and lungs unless there are clinical signs that indicate there may be a problem.

The nursing assessments we do in the UK are different but that does not mean we don't do them

Specializes in ER/Tele, Med-Surg, Faculty, Urgent Care.
umm, how do you assess for changes if you don't do the entire assessment to see what has changed? :confused:

i guess this depends on where you work. this is expected in the icu where the nurse typically has 2 patients. anything can (and sometimes will) go wrong, and you never know what bizarre or potentially life-threatening change you will find with your next assessment.

to do a complete head to toe, checking cranial nerves, romberg, muscle strenght, ears. eyes, thyroid, dts's etc etc. would take about 30-45 minutes. as a fnp that teaches assessment i would say that it would be time consumming and not necessary to do a complete head to toe & usually we are doing focused exams, yeah you can check pupils and mentation but not do all the cranial nerves. if a patient has pneumonia then yes i am checking lungs sounds, pulse ox, nailbeds, how they are breathing but if they do not have an ng tube then i am skipping abd, reflexes//dt's/muscle strenght but would of course do cardiac assessment (rate/rhythm, bp, pedal edema) the last hospital i worked we got 9-10 patients per nurse, so on a 12 hour shift, with giving meds/crushing meds/dressings/feedings/incontinent patients, then documentint the assessments, there was not much time left to doanything else. so it does depend on the type of patients/unit but complete head to toe takes lots of time.

Specializes in CVICU.
to do a complete head to toe, checking cranial nerves, romberg, muscle strenght, ears. eyes, thyroid, dts's etc etc. would take about 30-45 minutes. as a fnp that teaches assessment i would say that it would be time consumming and not necessary to do a complete head to toe & usually we are doing focused exams, yeah you can check pupils and mentation but not do all the cranial nerves. if a patient has pneumonia then yes i am checking lungs sounds, pulse ox, nailbeds, how they are breathing but if they do not have an ng tube then i am skipping abd, reflexes//dt's/muscle strenght but would of course do cardiac assessment (rate/rhythm, bp, pedal edema) the last hospital i worked we got 9-10 patients per nurse, so on a 12 hour shift, with giving meds/crushing meds/dressings/feedings/incontinent patients, then documentint the assessments, there was not much time left to doanything else. so it does depend on the type of patients/unit but complete head to toe takes lots of time.

yeah, we definitely don't go into all the cranial nerves since a great majority of our patients are unconscious/sedated, and we certainly don't have time either! generally one of my "typical" assessments consists of the following: mental status, pupils, strength/commands, pulses in all extremities, capillary refill in all extremities, lung sounds, heart sounds (5 points), ausculate/palpate abdomen/check ng placement/residual, check wounds/drain sites, skin assessment, level/zero transducers and get cuff pressure if patient has an art line. we also read our own telemetry strips.

Specializes in Med surg, Critical Care, LTC.

When I first started in nursing, I was a float nurse. I was sent floor to floor wherever their may have been a call in or someone on vacation. I was hardly in the same place two days in a row. Consequently, I didn't really belong anywhere and none of the nurses on the floor felt any obligation to "watch my back" so to speak. So, I learned it was sink or swim for me, and I chose to swim.

I also learned that many nurses document whatever the shift before them did. Almost daily I found considerable differences with my head to toe assessments (which I always did) when compared to previous shifts. For instance, for a solid week pt. A's lungs were clear for 21 shifts. I get rales to midline. Pt. B, has abdomen soft with +BS in all 4 quads for the previous 5 days. I find acute abdominal pain, negative BS, rounded/firm abdomen - pt states he's been c/o of abd pain for 2 days. Pt. C - +homens, calves obviously not equal in size, negative pedal pulse on the swollen side. You get the point.

I couldn't trust anyone elses assessments, because, without exageration, I would find differencess daily - even though every other shift that week found the same thing.

This is why head to toes are done. The majority take minutes to do. As your talking with the patient, you'll know their mentation, you can see their skin color, can they speak in sentences or are they SOB? Have they had a bowel movement recently? To test their short term memory, ask what they had for breakfast. Listen to lungs, abdomen. are they moving all four extremities? Urin out put adequate? PP and cap refill. Are they having any pain? Done - they you can do a more focused assessment on their particular problem as the shift permits. - at least you've got a good base or handle on your patients picture as a whole.

Blessings

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