Assessments

[hmt]

Have you ever read pt. assessments that were so different from yours, it was alarming. Does staffing, stress or attitudes affect the documentation of assessments;or are they just poor assessments. Have you ever had a pt. tell you, you are the 1st nurse in 4 days that has checked their feet, yet you read documented feet assessments. I am looking for articles and references about this issue and any comments.

[shee1a]

Hi. I must say I have seen the same thing, however some of these were my assessments. Some people if very unstable can change quickly. I have listened to peoples lungs and find base crackles and go back 1 hour later and hear crackles half up their back. Murmers on people can come and go depending upon pt position and fluid status.

The foot thing is what got me in your note. I have had that happen to me. I checked this guys feet while i was changing his slippers, felt for pulses etc. I was all one fluid motion you know what I mean. Anyway while giving off report to the next nurse, we went into his room so I could show her his abdomen wound. Anyway she says hows his feet and he says no ones looked at them. This patient was definately alert and oriented, he may have not realized that I could check his feet without making a big production of it.

However, having said that I do know waht you are saying sometimes it does seem that one assessment is quite different from another. Is everyone doing what they say they are doing? Lets hope so, but I doubt It. Some will be lack of knowledge on proper ways to do something.

Yet i feel a big piece will be to many things to do in to short of a time. Little things , if not relevent to the primary diagnosis are going to be left out. If one has a 25 yr. old appy feet are not a priority, if that nurse is running her legs off to keep up secondary to high pt:nurse ratios.

Just my opinion.