Clinicals and patient care.....

[D.R.A.]

I am curious how other programs handle patient care days. Do you as a nursing student perform and chart head to toe assessment? If so, does a RN also perform and chart a head to toe on the same patient?

[BellsRNBSN]

I am curious how other programs handle patient care days. Do you as a nursing student perform and chart head to toe assessment? If so, does a RN also perform and chart a head to toe on the same patient?

In my program and at my clinical site, it just depends on the RN you're working with. Some of the RNs expect me to do the assessment on my own and chart it myself while other RNs do the assessment with me, chart their own data, and let me fill in any other information that I gathered on top of that.

Also, the only time I ever did a FULL head to toe assessment was when my clinical instructor was checking me off for it. They are always focused assessments with VS, cognition, heart (apical pulse for 1 full minute), lungs, overall skin (especially back, coccyx, and heels), IV/catheter sites, and any wound or surgical sites being the most important to assess, and anything else that is especially important and particular to that patient. Especially now that we are caring for two patients each shift, you just don't have the time to perform the full assessment with checking the hair, hearing, PERRLA, gait (this often isn't possible, with the bedridden pts), etc. etc.

I'm sure it's different for everyone, but that's how we do it!

[CorazonDeOro]

I am curious how other programs handle patient care days. Do you as a nursing student perform and chart head to toe assessment? If so, does a RN also perform and chart a head to toe on the same patient?

We are expected to do our own and chart it, but the RN can decide to do her's as well if she would like, but usually they just let us do it and our instructor signs it off.

[~Mi Vida Loca~RN, ASN, RN]

I am curious how other programs handle patient care days. Do you as a nursing student perform and chart head to toe assessment? If so, does a RN also perform and chart a head to toe on the same patient?

Here it depends on the facility. We have 2 major hospitals in the area with 4 hospitals we do clinicals at. 2 for each company. One of the companies students charted everything but nursing notes. We charted head to toes. We even charted meds but a thing popped up for a nurse to co sign. The nurses always did their own assessments too, they had to, but if they agreed with us they could just sign off on it. At this other facility I am at students can pretty much only chart on CNA stuff. For billing reasons or something. I dunno. So the nurses still have us to our assessments, and go through it with them and they chart on it.