Afraid of being trained as a bad nurse.

[NightBloomCereus]

I'm a new grad orienting on a tele floor. My worst fear as a nursing student and now as a nurse is not having the skill and foresight to tell if my patient is declining. I don't ever want someone to get worse because of a lack of skill on my part. I always thought the key to this would be learning good assessment skills, so this is something I want to perfect so I can anticipate my patients' needs.

I'm confused because I'm orienting and have not seen a single nurse conduct a head to toe assessment on a patient. If the nurse has not had the patient before, they spend maybe 30 seconds on the assessment. If they had the same patient the previous day, they just "check on" them, look at the IV or the wound, maybe a pedal pulse, but that's it. We chart by exception, so the nurses are essentially charting that things are within normal limits that they never even checked. I've seen nurses go their entire shift without using their stethoscope, and many don't carry one.

I know nurses are extremely busy, but I'm honestly terrified right now because I don't want to pick up any bad habits, neglect my patients or be "that nurse" who didn't notice when their patient was going down the tubes. I'm wondering whether what I'm observing is bad practice, or normal and ok. How do you assess your patients at the beginning of your shift? I just want to make sure I'm on the track to being a good nurse and not a bad one.

[danceyrun]

This is interesting. Even though you aren't seeing anyone else do an assessment, are you? You should assess each patient per your facility's policy. Make sure you do your own assessments no matter what, as well as knowing how to locate policies on the intranet. You will be surprised at how quick you can notice that a patient is declining.

[Lev, MSN, RN, NP]

I think it's bad practice, and I do know some nurses do this. Stellar nurses will not. I ALWAYS do my own assessment, which takes me 2-5 minutes depending on the patient. Assessments do not have to be head to toe. Sometimes I start feet up as I put on SCDs.

Basics include

Orientation and Neuro status (Talk to them)

Pupils (if neuro patient or neuro checks ordered)

Radial and pedal pulses at a minimum (with other pulses as appropriate)

Heart and lung sounds (I may or may not listen to all five heart areas - it depends what's going on with patient)

On oxygen?

Presence of edema

Presence of bowel sounds

Are they passing gas, moving bowels, not nauseated?

Are they voiding urine?

Any lines or tubes anywhere are assessed. JPs, PEGs, NG tubes, nephrostomy tubes etc Flush all your IVs, even medlocks that aren't being used.

Skin - turgor, capillary refill, warmth

Assess wounds, especially surgical sites to look for bleeding

Don't classify a wound, especially pressure ulcers unless you've seen it yourself

If there are lots of skin issues, I will do a skin assessment later when I have more time.

When you've had a patient for a couple days in a row, sometimes you can predict their assessment before actually listening to them. But always make sure. This is where you may see decline. Especially when it comes to mental status changes. Those changes can be subtle. You will develop instincts and learn to trust your gut. I don't have a great deal of experience, but you will find that after 6 months or so, you will look back and say "Wow I am really coming along."

[iPink, BSN, RN]

If you have these concerns please speak with your preceptor.

Are you sure the other nurses and preceptor are really not doing a full assessment? As a GN, you're going to move slower when doing your own assessments and may spend a long time in the room. But, an experienced nurse can go through a full assessment in no time and a GN may not be aware a full assessment had been conducted.

For example, when I enter my patient's room I introduced myself and shake their hands. From a handshake, I moved my fingers down and assessed radial pulses and skin and by listening to their responses to my questions, I've assessed neuro status. That took about 10 secs. From there, I move down. When you work on a busy critical floor, you learn to make your assessments look seamless, but at the same time doing a thorough job to catch something that is not WNLs. That will come with time. Also, you learn to do Focused Assessments, which is what I do more often when I get back the same patients. Of course, patients with more complications than others, will take longer in assessing.

[NightBloomCereus]

Thanks so much for your responses! My gut feeling tells me it's bad practice, and I will definitely do a full assessment on my patients regardless of what I'm seeing other nurses doing (or not doing) especially since it's my patients' lives and my license on the line. In time I'll figure out what I especially need to look for depending on their diagnosis.

I appreciate the helpful suggestions to know my hospital's policies (danceyrun) and the list Lev

I know there are many things you can assess in your patient from just talking to them, helping them to the bathroom etc. as iPink pointed out, and it's true that there is no way I know whether every nurse is doing what they're supposed to. But I followed my preceptor around for 12 hours and she did not use a stethoscope even once. There's definitely something missing there. But I'll be sure to do what's right and bring up anything with my manager that I really feel I need to.

It's comforting to know that you all think in time I'll be able to pick up if my patient is declining. I'll do the best I can...Wish me luck!