clinicals, nursing thru the day

ParkerBC,MSN,RN, PhD, RN · Dec 7, 2011

I have provided an attachment of a complete head-to-toe assessment. Take a look at it. When your instructor says a "focuses assessment", it means focusing on a particular system(s) rather than all of them (like a full head-to-toe). So, what determines which system(s) to focus? Look at the medical diagnosis. For example, if my patient presents with Congestive Heart Failure, there are certain things I am assessing. I am listening to: Lungs, heart, checking peripheral pulses, and lower extremity edema. There is more I would do, but I am trying to make this short and sweet so that I don't overwhelm you.

As far as a routine, ask the nurse with whom you will be working what her routine is for a shift. She will tell you. It will give you an idea. However, don't fret so much over a routine. There are nurses who have been working for a year or more who are still trying to find their routine. It isn't something you are going to get by doing clinicals for six hours a day once a week. Generally, how a day works is this...get report, make a plan for the day (write down meds and times of administration, fluid information, and needed interventions for the day.) Again, this is something you can ask your nurse about. See what kind of system she is using to plan her day. Go introduce yourself to your patients (while you are doing this...look at their IV fluids...do they need to be replaced soon and are they the correct ones? Is your patient running a piggyback that will soon be completed and is it the correct medication? Take a look at the IV site...is it okay? Before leaving, tell the patient you will be back in a few minutes to do an assessment. Ask if there is anything you can get him/her when you come back. Now, figure out who needs assessed first. Then starting assessing your patients. When going in and out of rooms, refill the water pitchers. Okay assessments are now done. You should be getting ready to pass AM meds and complete AM treatments. When those are completed, start with cleaning the patients up. Then get ready for afternoon med passes and treatments.

Again, check with your nurse to see her routine as she has worked on that unit for a while. I hope this helps you. If you have any other questions, I will be more than happy to answer them.

Good luck to you!!!!

Physical_Assessment_Notecard_Info.doc

NCRNMDM, ASN, RN · Dec 8, 2011

A focused assessment means that you aren't doing a full head to toe on every patient. In a focused assessment, you are going to listen to the lung, heart, and bowel sounds, assess the skin, and check pulses, capillary refill, etc. You are not, however going to do a comprehensive exam. You aren't doing a full neuro exam, unless you think they have altered LOC or mental status, or if they have a neuro complaint. You aren't doing a full assessment on things like eyes, ears, nose, mouth, etc. You aren't noting that the trachea is at midline, that the ears are situated normally, that the face is symmetrical, etc. You are just doing the minimum while still providing your patient competent care. You tailor a focused assessment based on the patient's complaint, their needs, and their admitting diagnosis. As far as how the clinical day goes, I will type out my schedule for you. During the first semester, we were doing 12 hour day shifts on Saturday on a post-surgical floor that also accepted medical over flow and ICU step down. We will be on the same floor next semester, but we will be there from 1800-2400 two times a week. We were responsible for all the nursing care for our patients this semester, so this schedule should help you a bit. Here it goes:

0745- Leave report, go check on my patient/patients, and take the morning vital signs.

0800- chart vital signs in the computer (including pain assessment), and look up information about my patient (such as medications and when they are due, admitting diagnosis, lab information, and notes about how they did during the night).

0825- Go back into the patient's rooms and ask them if they would like to take a bath, if they need help, or if they would like to bathe independently. If they need help, assist them with bathing, oral care, and hair care.

0845- Chart morning care in the computer, or chart that the patient performed care independently, or refused (whatever the case may be).

0900- Administer the first set of medications to patient/patients.

0945- Check to see if breakfast has been finished, if the patient wasn't NPO, and record intake on I&O screen in the computer. Ask the patient if they have urinated, or check the Foley, and ask about bowel movements at this time. Chart any output on the I&O screen.

1000- Carefully review all lab work, all home medications, admitting diagnosis, surgical report, pathology report, etc. During this time, administer PRN meds (such as pain medication) and chart all medications and assessments in the computer.

1100- Administer the second set of medications to patient/patients.

1200- Get the second set of vital signs, including a pain assessment, and record this information in the computer.

1245- Check to see if lunch has been finished, if patient wasn't NPO, and record intake. Assess output at this time. Chart both of these things on the I&O sheet.

1300- Administer the third set of medications.

1400- Begin copying down lists of all lab work, medications, treatments so far, radiology reports, surgical reports, and begin working on clinical snapshot and nursing diagnoses for the patient/patients.

1430- Perform head to toe assessment if this hasn't already been done at some point during the day.

1500- Administer the fourth set of medications.

1600- Get the third set of vital signs.

1700- Administer the fifth set of medications.

1745- Check to see if dinner has been finished, if patient wasn't NPO, and record intake. Assess output at this time. Chart both of these on the I&O form on the computer.

1800- Chart head to toe assessment, and check to ensure that all procedures have been charted along with I&O, wound care, dressing changes, drain emptying, medication administration, etc.

1830- Administer any medications scheduled for 1900, if the patient has them ordered. Chart these medications.

1900- Post-conference. Our post-conference usually doesn't start until about 1940.

This is just a general schedule, and things change throughout the day. Patients need extra medication, new orders are written, patients are discharged or transferred, IVs infiltrate, NGs are pulled out, beds are soiled, etc. This is just a general guideline as to how my day usually goes. If I have a surgical patient, my day is a bit different. If I have an ICU step down patient, my day is different. If I have a medical patient, my day is different. You have to tailor your day to your patient/patients and their needs.

GonnaBSN · Jan 2, 2012

Wow! Nice summary. It helps bunches. I know it took time to write out, and I appreciate it!

NCRNMDM, ASN, RN · Jan 3, 2012

You are very welcome. If you need any more advice or tips don't hesitate to private message me, or add the question to this forum. I will be happy to help in any way that I can.

CharcoalPepper · Jan 4, 2012

What a great scheduling resource. Thank you for taking the time to write it out. I'm sure it will be very helpful for many students.

grpman · Jan 7, 2012

Wow, this thread helped me too. Thanks for the posts. This is the first time I've copied and pasted on Allnurses. Kudos to all.

avalonsun07 · Jan 12, 2015

That is great, thank you!