Do you do the full head to toe patient assessment?

[aywl]

To be honest, do you do the full head to toe pt assessment every shift?

[loriangel14, RN]

Nope.

[Pangea Reunited, ASN, RN]

I do the first day I have a patient, but if I come back the next day, I get more focused.

[petethecanuck]

And what happens if there is a change in your patient that you missed because you didn't do a full head to toe on your next shift?

Is it a hassle to have your patient roll over so you can take a quick look at their bottom checking for pressure sores? Sure.

However, it's more of a hassle having to do a dressing change on said bottom because you were lazy and missed a pressure sore forming.

[loriangel14, RN]

I just mean I don't do a system by system assessment every shift. A skin assessment and vitals is usually enough unless there is a problem you need to focus on (e.g. respiratory).We have Personal Support Workers that get most of the patients up and dressed so they alert us to any changes.

[Sun0408, ASN, RN]

Depends on the setting. In LTC you can't do a full head to toe assessment on 20-40+ pts. When I was a M/S nurse, I did focused assessment but listened to each pts heart and lung sounds, did a quick neuro and skin assessment as well..I am in the ICU now, we do full head to toe q4 hours. Ever drain, dressing, PIV, fluids etc are noted and documented on as well as skin and neuro assessment.

[aywl]

Why I asked this question? Last Friday, my manager pulled me to her office, told me one nurse in our unit complained me didn't do the full head to toe assessment sometimes, I feel so surprised because:

1. As a experienced nurse, do u really think necessary to do the full head to toe assessment to every pt every shift? I don't think so;

2. I feel so surprised why my co worker watch me so closely and raised so stupid questions, i have been a pt in ER and surgical unit, the nurse only did vital signs and focus assessment, I think that's enough, why my co worker complained me to manager this stupid question? In our surgical unit, Basically we do vital signs Q shift or Q 4 hrs, if VS. abnormal, then nurse have to do the focus assessment, that's my practise;

Please tell me why some co workers are so noisy and stupid, thanks for everyone's reply;

[Fiona59]

Does your unit use the multi-page assessment booklet? If they do, you pretty much do a complete assessment when you fill up the two page assessment each shift.

From what you have posted in other threads it sounds as if you need to be very careful in your practice. Any future meetings with your manager you may want to have a union rep with you.

[A&Ox6, MSN, RN]

Also, if you have to check off boxes on computer, that pretty much is head to toe, so if your not doing it or flubbing, it's in the chart and everyone can see

[aywl]

Technically, in order to fill the computer assessment forms, nurse should do the full head to toe assessment each shift on each patient, but in reality, how many nurses did that and it's really necessary?

To Fiona, you know I am a LPN, in our unit, I have a closed friend who is an experienced RN, she is one of our charge nurse, I asked her the same question, she said:"no, I only do focus assessment if there are abnormalities there." I agreed with her, but nobody complained her, why some nurses complained me? Just because she is a RN, I am a LPN?

[aywl]

And what happens if there is a change in your patient that you missed because you didn't do a full head to toe on your next shift?

Is it a hassle to have your patient roll over so you can take a quick look at their bottom checking for pressure sores? Sure.

However, it's more of a hassle having to do a dressing change on said bottom because you were lazy and missed a pressure sore forming.

Pete, for the skin opening and dressing, of course I checked every shift, the head to toe assessment in my unit, means system by system, lung, GI system (bowel sound), I know some new nurses listen to the lung every shift to every patient even if patient's o2sat is 100%, which I think it's totally unnessary;

[A&Ox6, MSN, RN]

And in LTC your residents don't get constipated? They don't have urinary retention? Mental status sometimes A&Ox3 but still not totally ok. What about musculoskeletal. If you aren't consistently assessing, how do you prevent falls?