Do nurses do...

If a nurse has not done the assessment, they should not be charting...I have found on many occasions that what I was told in report, was not the correct info. For example, had a pt who supposedly had a "red area" on his sacrum. He was bedbound, and on a specialty bed for potential skin breakdown. When I assessed, the "red area" was in fact a stage II decub. I shudder to think how many nurses had not thoroughly assessed this area...since it obviously did not happen in the time it took for me to get report. In addition, there was no documentation as to wether the decub was present on admission, or happened at the hospital. I reported it to my Clin II and there was a big to do about it since I had gotten a conflicting report that there

was no breakdown.

The bottom line...assess always!

Amy

I usually do a quick general assessment at start of shift. Pedal/radial pulses. BP and temp. Skin color and temp. Respirations and if labored or not. I then assess through out the shift. If they are in for specific reasons ex surgery. then I always assess the incision and bo so before I do anything else. COPD breath sounds before anything else. Other stuff though gets done during routine care, turning or walking to the br I can see their back and bottom. Grips I also get when I get them out of bed.

One time though--we had a patient on nuero checks q4. I came in and the nurse ahead of me checked both R and L eye were equal and reactive to light...imagine my surprise when I did not see a L eye in the patients head, no his L eye was in a denture cup on the bed side table, it was glass!!!!

If we did full assessments like you are taught in nursing school we'd never get anything else done. The purpose of teaching that long assessment is simply to teach you HOW to do it. When you are on the floor you will do a more focused assessment.

Walk into pt's room and talk to them. This is your a&o assessment. Quick pupil check. Watch how they move in bed - everything moving? This is your neuro/musculoskeletal assessment. Add hand grips and foot pushes if neuro pt needing neuro checks. On to lung and heart sounds then belly sounds. Throw back covers and check DP/PT pulses - also assessing edema at this time as well as lower body strength and skin. If they have a wound/incision/chest tube/ostomy/whatever, you are assessing that whenever you are at that body part as you go from head to toe. Making them situp and roll over to listen to posterior lung sounds gets you a view of the backside skin. Whatever their main problem is will be the spot you concentrate on.

If you keep your eyes and your ears open the whole time you will learn a lot but you won't be doing every little step in one of the physical assessments that take 2 hours to complete. This more focused type of assessment gets you your needed info. As you get more experience it won't take you long at all and you will learn what questions to ask and what to look for concerning other potential problems that the pt doesn't have yet but can be seen if they have another disease/illness.

Nurses who chart an assessment without laying eyes and hands on the pt are lying. As a nurse, I am responsible for the care of that pt whether there is a student or not. My routine is to try to wait until the student does their morning assessment. Then I go in and do my assessment, tell the pt I am in charge but I am letting the student do most of the care. I assure them that I am overseeing the student for safety so they don't freak out. And I make sure that the student knows they are the nurse that day and I expect them to perform everything that they are allowed to perform up to that point. This works great, the student learns something, and the pt gets awesome 2 pronged approach care for the day.

Yup, my priority out of report is to do my head-to-toe assessment. Heart, lungs, Bowel sounds, pulses (radial/pedal),skin, LOC, SpO2, IV site, pain level, elimination, nausau/vomiting-this doesn't take long, and is my baseline for the evening.

Sometimes, circumstances don't allow for this to be done as quickly as I'd like, and I am very uncomfortable. I cannot imagine why ANY RN would chart that they'd done an assessment when they hadn't.

Here is what I do. On a day shift I get report check fsbs on my diabetics and then start getting my v/s . As I check v/s I Listen to lungs and heart check 02 sat, and Check for bs and abd distension , check for edema , rom , skintemp and skin turgor. As I am talking to them I am assessing loc , mental status , c/o pain and color. Does not Take long but with 16-24 pts its got to be quick. Obviously if there are specific things going on my assessments will be ongoing. :nuke:

At shift change we do walking rounds, which is great because you have gotten report and you can give a once over during rounds, eye the fluids infusing, pca infusing rated, check iv sit, loc, etc. if you find something not wnl the nurse from the previous shift is there to see also and possibly assist with a pt's immediate needs. After I have made rounds I go back to my pt's rooms and ausculate heart, lungs, bowels, check pulses all extremities, check vss, our cna's are great to get anything out of range to us asap. Also thru my shift I communicate with my aid, during showering there may be a reddened area or contusion I have not seen yet, so I also depend on an extra set of eyes.

The shift I worked was 0245 to 1515 and so we were there way before the students showed up.

We were allowed to go to report if we wanted to get to the hospital early. I reallly liked hearing what the nurses had to say and how report actually went.

Walking rounds sounds awesome.

Thanks guys for the info. I just want to make sure that I am on the right track with my lines of thinking. :)

I am with many of these fine nurses in saying I do a quick head to toe at the start of shift, and also hit the focus areas dependant on Dx. I have twelve hours to do the rest!

The thing is, and I remind students of this...you may not see the intervention...especially how you learned them because you are a beginner and need the step by step assessments till you learn them like breathing..LOL...but I can walk in a room and assess a patient in a matter of minutes just watching them talk, walk, move in bed, mannorisms, conversation and the like! You too will become that quick...but for now do the motions, and don't assume the nurse DIDN't do it!

For example, if I have a person carrying on a good conversation with me...using their body language...I know that their blood pressure/pulse/respirations are at the patients norm because they couldn't sustain conversation or move if it was not the case! If I don't have the time to break out the BP cuff or steth at that time...at least I know they are stable on the big three! If I feel a nice radial pulse and pedal pulses...I know they are above 90 systolically if I am rushed (a nice little pearl there!). I watch facial expression and all body language to determine any deficits in facial and extremity responces or slurred/confused speach.

I always look at the room as well! All are my tubes working, how is the room organized...is it arranged for ease of movement to the BR (then I can make a judgement on their ambulation, lack of, or if they are getting oob when they shouldn't be..LOL!). Is the tray table easily accessable...or does the patient care/know that it is even there (cognitive) or even did the last staff member just forget to put it back. Phone and call light placement (same thing)...and I may even ask...."oh now where is that pesky phone/call light" and a patient will typically talk to me about it...another check on A/O and ablity to reach or use these items!

See...you can do this in a few moments as you walk around a bed! I will also count respirations during a pause when I am speaking to the patient (and they aren't)...

So there you have a few of my techniques for busy mornings...

What I learned in nursing school as far as a physical assessment was very painstaking...if I did that for all of my pt's, I would still be charting till my next shift the following day. I have learned over the years how to quickly do a head-to-toe assessment, you might miss it if you blink since I have anywhere from 4-6 pt's to see. I concentrate more heavily on the systems that the pt has affected...say if they have pneumonia, I will be really honing in on what those lungs sound like in all areas of the chest, really looking high and low for cyanosis, retractions etc. There are other things that I save for when the timing is right like skin assessment with bathing etc. Bottom line minimum for me is head to toe and quick, which comes with practice. And don't chart what you don't do, not good practice.

I do pretty much the same as Triage RN & Beary do. I work telemetry so I'm also checking for edema, the lung sounds, constantly monitoring the tele strips, fluid intake & output, etc. etc.