Assessments every shift? - page 4

So, I'm about to get out in the real world of nursing. I worked as a tech for awhile on a busy med/surg unit so I feel like I have a little real world experience that will come in handy. I realize... Read More

  1. by   ThePrincessBride
    I am a nursing student who caught a heart murmur that was charted as normal by a licensed nurse. The pt told us that this murmur had been present prior to her admission. My instructor and I informed the charge nurse. Needless to say that I was shocked to see such laziness and inaccuracy in assessment processes and I have yet to seen a nurse do a full body assessment on a patient.
  2. by   alduhkneel
    I work on a cardiac tele floor. Assessments are required every shift for us (I don't see why it wouldn't be for any other facility, haha). I always do cardio/peripheral vascular and lungs since were are a cardiac floor. Everything else gets player by ear depending on the patients needs andwwhat the patient is like in report and when I go to see them. Skin assessments are also required every shift for us, but I won't automatically go rolling every person over (eg if they're alert and oriented, etc). Just do what wouldmake the mosy sense and what's most pertinent to the patients needs!
  3. by   Nurse Mentor Nancy
    Each patient should have had an initial/admission nursing assessment. That is the time when a head to toe assessment is critical. Then diagnoses were made with accompanying goals and interventions. Now it is up to you to evaluate daily whether these interventions are effective in progressing toward the goal. The nursing care plan should guide you to what nursing assessments need to be done on your shift. Most patients do not need a head to toe assessment every shift but an assessment focused on the nursing diagnoses identified in the care plan. Of course, as you are interacting with the patient, you are observing how they are doing mentally and physically and may pick up a critical change that iis not in the care plan.
  4. by   Morainey
    I check bums during bathroom trips, if people are walkie talkies. If they're little old people who aren't getting up for whatever reason (I work ortho, so people with fractured hips or intractable back pain, etc) I try to sneak in and look while people are on the bedpan or getting washed. I've seen nurses who don't carry stethoscopes... ever. Also, I've seen documentation where I heard wheezes or crackles or whatever, then mysteriously their lungs were clear until I came back to work 12 hours later. *sigh*
  5. by   Nurse Mentor Nancy
    Are you saying that nurses that don't carry stethoscopes are not doing physical exams? Maybe they get the stethoscope when they need it instead of wearing around their neck. (That's what I like to do, but that's me.) I have found that different nurses' physical exam skills vary. Also, when I was going to school to be a ANP, 5 different cardiology residents would have 5 different interpretations of heart sounds. Alos, patients may change from shift to shift. If you suspect a nurse is not doing physical exam or is not skillful enough in this area, consider talking with your manger to get this nurse the necessary training.
  6. by   SwansonRN
    In my opinion I am assessing all day long, every time I'm in the room with a patient. Technically I document a full head-to-toe once, but if something major changes, like the patient gets intubated, I'll go in and add another assessment.

    In the documenting program my hospital uses, there's a copy forward option that automatically fills in the assessment that was last filled in. It's a lazy nurses dream!! I will admit, I do use that button at times, but only so I can compare the last assessment with my own. Copy forwarding someone else's assessment is just asking for trouble.
  7. by   mappers
    When I was in the hospital, we had a copy function also. I only copied my own assessments and only if they were from the previous day. Then I reviewed everything and changed what was now different. New patient that I had not had before, or if it had been a few days, I charted from scratch.
  8. by   anotherone
    Each pt , each shift. Listen to heart , lungs, abdomen. Palpate abdomen. Ask about bm, urinating, ambulation. I try to get them all to use the urinal or containers placed in the toilet to measure out put ( some refuse or ignore, which I chart), check IVs ( if fluids running, check every few hours. YES, EVEN IF IT WAKES THEM AT NIGHT, OH WELL), check pupils, strength and peripheral pulses . Check any incisions . Also any ostomies and known about wounds. The wounds may not be checked at the same exact time as the rest of the assessment. Depending on why they are there, I than do a more focused assessment. Example, a pt in for an ortho surgery is going to get more extremity checks than a pt there for an ENT procedure. The ENT pt may have me check thier throat for bleeding, while the kidney failure pt won't. Pt in from a MVA or possible stroke will get more neuro checks than the cystic fibrosis pt getting IV abx.