assessment do you do?

wow- you are setting yourself up for disaster. How can you possibly know who "might" have a problem? How do you evaluate change in condition? What if you failed to pick up something and the patient did not know or was unable to tell you something was wrong? I believe this is why we have nurses - to assess patients thoroughly. I recommend you take that extra time rather than spend it in court explaining why you neglected to do an assessment, which by the way, is what you are being paid to do.

I find I can get an idea of a pts. orientation by simply talking to them while I do my assessment. But to find out if they have a cataract, non-reactive pupil, missing teeth, left/right deficit, lower extremity weakness, edema, pressure ulcers (any stage), old surgical scars, etc., I have to do the full once over at some point on my shift. I used to hate to "bother" the pt with all of this stuff, but I came to realize its all necessary. I really think that a lot of pts want their nurse to fully examine them and question them, of course, not while they are trying to sleep or eat. I take my cue from the docs that make rounds. I work in a teaching hospital and they often perform lengthy assessments and uncover valuable insights in the process. Besides, it makes me feel I am more than a pill pusher/documentation clerk.

Maybe you need to pose this question to other nurses with whom you work, or better yet your clinical nurse educator, to see what sort of neuro assessment is expected in your area.

Our basic, expected assessment does not include checking grips, pupils, etc. Our basic neuro assessment form asks: Any swallowing issues? Gag reflex? Equal movement of extremities? Gait? There are different choices to click on within each of these areas. You can perform and document a more thorough assessment; but that is not expected of you unless there is something neuro going on with the pt or there is an order for a complete neuro check.

I do not perform a thorough neuro assessment on every patient; that's just silly and a waste of time. My patients at risk for neuro complications or admitted with some sort of neuro diagnosis: you bet. My walky-talky who has a gastroenteritis, who is admitted for fluids and zofran for a whole 8 hours prior to discharge: no.

The newer you are, the more thorough your assessments should be. Or rather, consciously thorough. As you gain experience, you will find that you do not need to be as thorough, in part because you are able to pick up on these cues sooner, and you find ways of performing these assessments without consciously thinking about it. Every time I hand a patient a pill or cup, every time I walk them to the bathroom, every time I help them to the commode, reposition them in bed, or watch their face while they speak, I'm performing a neuro assessment. It is just second nature.