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Discussion

Do nurses do...

Do nurses really do head to toe physical assessments everyday?

From my experiences in clinicals for the past year, I can honestly say I have never seen a physical assessment done, I have seen them charted on a patient I was taking care of, but did not see them happen. In fact the nurse even made the comment that she was glad the patient had a student b/c she had been so busy that she had not had time to lay eyes on that patient yet, when I went to filll in the flow sheet for my physical assessment it was filled out.

I am by no means being critical of the nurses I had the pleasure of working with, I am just wondering.

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I absolutely do not do a head to toe like I did in nursing school (testing the cranial nerves? In order?)

However, I like the PALS model of "assess-categorized-decide-act". From across the room, you assess a child "in general." Then close up, I start at the top (fontenels, pupils/eyes, nose, mouth, face) in my "hello, sweetheart" rubbing of the head. Then I usually listen heart lungs (back and front) belly (x4). Feel belly. Pulses arms and feet. And the, of course, focused on whatever the dg. calls for. Call it a day.

Is that "head to toe?" It's probably a bit quick, but...

I have my embarrassing moments (had to admit to my fave MD that I haven't seen an abscess, report was that the packing was removed 2 days ago. He and I went in together to look - and it's still packed. I'd had the pt. for almost 6 hours. I'm still blushing - and honestly, feel like hekk about it.)

But generally, I think I'm pretty thorough.

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Frankly, I never had ample time to perform head-to-toe assessments when I was responsible for 70 residents during night shift at a local nursing home. To be perfectly blunt, I never did them. However, I never lied or documented a head-to-toe assessment that never occurred.

A minimum assessment should fill out all the required blanks on the flowsheet honestly. That would include vital signs, lung sounds, pulses present, mental status, bowel sounds etc.

I never could do a focused assessment; it meant having to come back in fill in the blanks later. I prefered to do the whole assessment one time and chart it then.

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