Jump to content
2019 Nursing Salary Survey Read more... ×

Do you do the full head to toe patient assessment

Canada   (8,292 Views 32 Comments)
by aywl aywl (Member)

3,941 Visitors; 133 Posts

advertisement

You are reading page 2 of Do you do the full head to toe patient assessment. If you want to start from the beginning Go to First Page.

3,941 Visitors; 133 Posts

Anyway, maybe I change my questions as followings are better:

When you do your assessment, if pt's o2sat is 97%, will u still listen his lungs sound? If pt had bowel movements 6am, will you listen to his bowel sound at 10am?

These questions are more specific to our unit;

Share this post


Link to post
Share on other sites

loriangel14 works as a hospital floor nurse..

6 Likes; 1 Follower; 35,829 Visitors; 6,922 Posts

Why would you listen to the lungs when the sat is 97%? I would only listen to the bowel sounds if there was an issue.

Share this post


Link to post
Share on other sites

3,941 Visitors; 133 Posts

This is exactly what happened in my unit, new grads listen to every pt's lung even if at night, even if o2sat is 100%, listen to the bowel sound every shift even if this are no issue there, I think some patients also expect every nurse every shift to do that;

That's why I raised my questions in here;

I worked for a busy medical floor before, we do the focused assessment only if there is an issue;

Share this post


Link to post
Share on other sites

Sun0408 has 4 years experience and works as a RN.

35,744 Visitors; 1,761 Posts

How would you know there isn't an issue unless you listen?? Yes, lung sounds on all pts, heart tones as well as bowel sounds.. It takes what, less than 5 minutes to listen to all three.. In LTC facilities the guidelines are a bit different than in an acute care setting..

I have had pts transfer to the ICU, sats 97% on room air crump over several hours, lung sounds diminished on the left.. Stat PCXR completed and showed a large L pneumo.. SBO missed for days until that area perforated. Both could have been avoided..

Share this post


Link to post
Share on other sites

12,885 Visitors; 905 Posts

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' date=' how do you prevent falls?[/quote']

Do you work LTC?

It is impossible to do a full exam every shift. And unnecessary. Most of the residents don't have immediate health concerns that require an exam. Of course, if there is a change of condition that requires an assessment it's performed.

Share this post


Link to post
Share on other sites

1,166 Visitors; 41 Posts

I work on a very busy medical unit as well. I do focused assessments on my patients daily and as needed if there's an issue and as ordered. I find with patients on medical floors, their conditions can change at a moments notice so I feel more confident if I complete my assessments (even if pt is stable) because if they go unstable you want to have a baseline and be knowledgable about your patients "exact current condition" at that moment. Some assessments I complete faster if I have to focus more on other areas. Ex: if pt is post - MI, I would want to complete a heart & lung assessment even if they are stable. Covers your butt and like I said it gives me a good baseline. Don't know how others practice but I find all my co workers do this. We have rpns on our floor as well and they practice the same when it comes to assessments. They just don't monitor the telemetry , the RNs do.

Sent from my iPhone using allnurses.com

Share this post


Link to post
Share on other sites
advertisement

3,253 Visitors; 42 Posts

I find that pts can have high/normal oxygen saturation numbers and still have crappy sounding lungs

Share this post


Link to post
Share on other sites

12,885 Visitors; 905 Posts

Why would you listen to the lungs when the sat is 97%? I would only listen to the bowel sounds if there was an issue.

I have people who can sat high but still have wheezy lungs. Happens more than you think. Like I said above I do assessments as indicated per the patient.

Share this post


Link to post
Share on other sites

itsnowornever works as a Studying like a madwoman until exit exams and NCLE.

15,671 Visitors; 1,029 Posts

I find that pts can have high/normal oxygen saturation numbers and still have crappy sounding lungs

I've seen full blown pneumonia stating 97%. You would be wise to CYA and take a quick listen. How long does it take anyway? 30 seconds max to listen for a change????

Posting from my phone, ease forgive my fat thumbs! :)

Share this post


Link to post
Share on other sites

1,340 Visitors; 33 Posts

I work in the ER and I only do focused assessments if you start assessing head to toe and doing the full assessment that we learn on nursing school I would spend all day doing assessments and not providing pt care. If I start digging to deep I will get into to much irrelevant things than what is pertinent to why the pt came into the ED today. I feel as though my job is to help provide pt care for the emergencies that the pt is seeking care for today.

Share this post


Link to post
Share on other sites

3,941 Visitors; 133 Posts

I work in the ER and I only do focused assessments if you start assessing head to toe and doing the full assessment that we learn on nursing school I would spend all day doing assessments and not providing pt care. If I start digging to deep I will get into to much irrelevant things than what is pertinent to why the pt came into the ED today. I feel as though my job is to help provide pt care for the emergencies that the pt is seeking care for today.

that's what I observed ER nurse did when I was pt , I think it's a good way; it's not necessary to do the full head to toe assessment;

Share this post


Link to post
Share on other sites

CodeteamB has 5+ years experience and works as a Registered Nurse.

2 Likes; 6,247 Visitors; 473 Posts

Yeah, you need to be assessing your patients, and this is a totally legitimate issue for someone to complain about. Perhaps you missed something important which the next nurse caught by doing a full assessment.

Vital signs are only the tip of the iceberg. An SpO2 reading does not constitute a respiratory assessment. As someone else pointed out you can have patients with severe respiratory illness who do not reflect it in their saturations.

I work in the ER and the first time I assess a patient they get a full assessment, no exceptions, they also get a focused assessment for their chief complaint q hour while in my care. When I worked on the floor I did a full body assessment on every patient, every shift. I have never had time management problems due to this. Once you get skilled (which you will if you are doing it daily) this takes a very short amount of time, and when your patient is all of a sudden not doing well you will be glad that you know which assessment findings are new.

Share this post


Link to post
Share on other sites
×