Assessments?

[blondy2061h, MSN, RN]

What kind of unit do you work on and what do your shift assessments consist of? If you work longer than 8 hours, do you repeat your assessment? Parts of it? How do you chart your assessments? For peds nurses, how do kids handle so many people wanting to listen to their hearts and lungs all day? Anyone have any stories about important things they've picked up on assessments?

I work BMT. For my assessments I listen to heart, lungs, bowel sounds. I look in their mouth and at the IV/CVL site. I check pupils and scleras. I check ankles and legs for edema. I feel radial and pedal pulses. I check all my pumps to make sure they're running accurately and my secondaries aren't clamped (HATE when people clamp secondary lines!!!). I ask my patients how they're feeling in general- pain, nausea. I look at sites where they've been getting subq shots to see how badly they're bruising, etc. We chart our assessments by system in the EMR. I chart a full assessment once a shift, pain q4h, and other things as things change.

I've caught many an irregular heart beat on exam. I also had one case where I had a patient with a fever that they weren't really sure what was causing. I listened to his lungs and heard obvious crackles. A repeat CXR (one day later!) showed a new pneumonia.

[carrie_c]

I work mother/baby. We do 1 assessment per shift. On the Moms, I check lungs, heart, bowel sounds, fundus, bleeding, incision (for sections), lady partsl and anal area, check for homens sign, pedal pulses, and edema. If they still have their IV and/or foley, I check those as well. On babies, I check heart, lungs, fontanels, collar bone, make sure abdomen is soft, check cord for bleeding, make sure there are 10 fingers and 10 toes, check for hip click, check reflexes, look at genitals, check for sacral dimple, and I also make sure they have 2 ID bands and a security box. I usually have 4 moms and 4 babies, so I am only able to do one assessment per shift (I work 12s) We chart EMR.

[OnlybyHisgraceRN, ASN, RN]

I work in CVICU and our assessments are full head to toe and are documented on a flow sheet twice a shift. My assessment goes as follows:

-Vitals signs vary. Sometimes it is done q15 min to every 4 hours depending on the condition of the patient. Pts. on pressors have vitals done every 15 min.

-Neuro exams are done twice a shift. GCS, perrla, sedation meds, cornea,gag, RASS,... you get the picture

-Respiratory- includes vent settings, assessed for weaning, sedation vacation, and etc.

-CV- EKG strips are printed and placed in chart with PRI, QRS, and name of the rhythm. Pulses are checked, temp. q4h, heart rate, rhythm, any gallops, murmurs and etc. are assessed. For our heart patients SVR, CO,CI, PAWP, CVP, and etc. are document as well.

-GI/GU- I's and O's every hour( including the 15 gtts the patients are on with dose over Mls). Some patients have hourly or q30min BGL checks due to IV insulin. General bowel assessment. If foley is in we have to write the date it was inserted and time.

Skin- any incisions, breakdown, and etc.

Lines- Lines are documented with insertion date, gauge, and etc.

Fall risk scale once a shift

Braden scale once a shift

This is our assessment in a nutshell. It is way more detailed than this but you all get the picture.

[BrandonLPN, LPN]

Well, I worK in LTC, so our assessments are obviously much much different. Of course we don't do an actual full assessment on everyone every day. Not only would that be unecessary, it would be a violation of their rights and privacy. This is their home. So we do focused assessments on a PRN basis. And we "assess" pts on the fly. When you have 49 residents and one LPN (me) on a 3-11 shift you get real good at eyeballing people for a few seconds and going by intuition.

I'm going to be honest, I don't think Ive done a single full head to toe assessment since nursing school. But I've caught my fair share of problems by being observant and doing focused assessments.

The CNA say the pt hasn't had a BM in 4 days, I assess him find a distended stomach, hypo bowel sounds and he's nauseous. Get an order for abd xray and sure enough, it's a SBO.

Another bed bound pt complains of

"knee pain". I assess him, find out there's a warm, red streak on his upper calf. Get an order for an US and find out it's a DVT.

Just last week, I was getting routine, weekly VS on a lady and noticed the pulse ox would jump from 60 to 130 for HR. I got a radial pulse that was 70 and irregular. The CNA tells me she always records 80 when the pulse ox does this for this lady because "it's in the middle". I get and order for a EKG and of course it's a-fib.

So these are the kind of

assessments we do in LTC. I make no aplogies for not doing a "complete" assessment. I do what I can with what I have. Just trying to dispel the rumor we are just "pill pushers".

[carrie_c]

I really don't think most nurses to a full head to toe assessment on every patient. We just don't have the time. We do vital signs every 6 hours, except fresh sections and babys 36 weeks get vitals every 4 hours.