Beginning of the shift.............

ericalynn, BSN, RN · Oct 25, 2007

I am a new grad and I always listen to heart & lungs, bowel sounds, assess pulses, check dressings, and depending what their dx is I go from there (neuro checks). Ask if they are having any problems and I try to let them know my plan for the shift. I personally think you need to do more than simply eyeball a patient to know where they stand, but as I said I am a new grad and still slower than most others so maybe I am doing too much..... Someday I'll figure it out!

bill4745, RN · Oct 25, 2007

Are we talking ER here? We normally focus on the pt's main problem - for a healthy young pt with a twisted ankle, I would not be listening to bowel sounds or lungs unless I had a reason to. On the other hand, a chest pain or sob pt would get a quick but thorough head-to-toe.

2shihtzus · Oct 25, 2007

While assessing and opening notes on 4 patients in 30 minutes would be ideal....I think that your preceptor might be rushing you a bit.

My advice:

When you do your initial assessment, go ahead and "eyeball" it, like your preceptor suggested. That doesnt mean you cut corners, but if you peek in on your patient and see that he/she is lucid, talking on the phone, walking to the bathroom etc...you know that his/her resp are even and unlabored, they are ambulatory, a & o x 3.

When I worked days, I would peek in on all my patients to make sure they were alive and breathing, introduce myself, then start pulling meds (we have a one hour window at our hospital for meds). While giving meds in the room, I would go ahead and assess lung sounds, bowl sounds, pulses, etc....it saved alot of time doing it that way.

On good days, I would be able to assess my patients, pass 9AM meds, and open my notes on 6 patients within 1.5-2 hours.

Everyone opens their notes differently. I never put "rec'd patient alert and oriented x 3, bed rails up x 2" because thats already covered in one part of our chart (its sort of like a check off thing on our notes). Avoid double charting and you will save yourself alot of time. My opening note is usually something like "Dx: cellulitis to LLE. Pt is a 54 yo male, resting quietly, 0 c/o pain, 0 s/s of distress. IVF infusing to LH at 100cc/hour via pump. LLE elevated on pillow. V/s stable. Will continue to monitor for acute changes." The entire physical assessment is already covered in the check off part of my notes, so I dont need to double chart about lung sounds or bowel sounds etc....

I know that everyone has a different way of doing things, and chances are there is going to be someone out there that will criticize the way I do it...but this is what works for me.

Sassybottom · Oct 25, 2007

NVM - Incorrect

2shihtzus · Oct 25, 2007

NVM? What does that mean?

jmgrn65, RN · Oct 25, 2007

I think clarification is needed this is posted in Emergency. AX are done very differently in ER vs the floor.

ERRNTraveler, RN · Oct 25, 2007

Like others have said assessing ER patients is a lot different than on the floor- in the ER we do focused assessments, concentrating on the area(s) that brought the pt. to the ER. If someone has an ingrown toenail, I'm going to spend maybe 5 seconds looking at their foot, and THAT'S IT! If someone has abd pain, I'll listen to bowel sounds, palpate their abd, and that's it. I don't listen to lung sound unless someone is in the ER for resp issues or chest pain. As an example, for someone complaining of ankle pain, I could do the following assessment in about 5-10 seconds: "Pt. A&O x3, resp unlabored. C/O pain to R ankle. Mild swelling noted to R Ankle, pulses WNL. No deformity noted."

Altra, BSN, RN · Oct 26, 2007

From your post I'll assume that this is in the ER, and that if you're getting report on the 4 patients you're picking up someone else's assignment -- the patients have already been in the ER for some period of time whether it's 5 minutes or 5 hours.

Anyone whose condition is potentially unstable - vented, potentially unstable heart rhythm, hypotensive, hypoglycemic or active chest pain ... see them first. Assess the major problem, determine if any immediate intervention is needed and document appropriately - vitals, rhythm, pain scale, appearance. If no immediate intervention is needed (i.e. chest pain pt. still having pain & still a little tachy on monitor but says that pain is starting to ease since NTG drip started ... document & move on ... chances are they'll be OK for the next 15 minutes.

In the ERs I have worked in, the most complete assessment is done only once by the nurse who initially had the patient - all documentation after that is not the type of head to toe assessment you would do on the floor but just re-evaluating the patient's major issues. Pt. here for LLE fx? If I pick up this patient at change of shift, I'm probably not going to listen to breath sounds - this has already been done once and the assessment is that his breath sounds are clear - unless he suddenly becomes SOB for some reason.

Any pt. you pick up who has not been in the room long and still needs labs drawn, breathing treatments, meds, etc. ... get that out of the way so their care isn't unnecessarily delayed.

If I pick up an assignment of 4 stable patients who are in various stages of awaiting lab results, awaiting disposition or admission, etc. ... my charting on all 4 of them at the beginning of the shift may simply read: "Pt. resting on stretcher, denies pain, respirations unlabored, awaiting lab results. Family at bedside." I'd include a set of vitals if it's been more than 2 hours since the last one or if their chief complaint warrants it. I'm guessing that this is where your preceptor is coming from ... to teach you to eyeball everyone quickly so that you can then devote your time to the unstable or potentially unstable patient without neglecting the others.

Good luck to you.