Head to toe assessment....how long does it take you?

jessiern, BSN, RN · Mar 17, 2008

Part of time management is learning to be more focused on the system in questions. I'm not saying don't do a head to toe, but if a patient comes in with abd pain N/V/D-make bowel sounds and abd your main focus. A COPD patient really pay attention to breathing pattern and lung sounds.

locolorenzo22, BSN, RN · Mar 17, 2008

true..you have to focus on the chief areas affected...but many of the nurses do that, and then will later say (as I'm giving a bath), what did their butt or their back look like? They know I'm a new grad in may, and have caught many stage I ulcers developing early when I go to bathe someone and roll them over to change the sheets.

At the LTC I'm doing clinicals at, I can get about 5 assessments done in 10 mins a piece...of course, I still have about 2 hours after report gets done to start meds, so that helps. I observe many of the nurses doing their head to toe while I'm getting something else set up in room, or doing something else with the patient....so I try to absorb as much as I can. It's a challenge....

BrokenRNheart · Mar 17, 2008

Part of time management is learning to be more focused on the system in questions. I'm not saying don't do a head to toe, but if a patient comes in with abd pain N/V/D-make bowel sounds and abd your main focus. A COPD patient really pay attention to breathing pattern and lung sounds.

More like part of MICRO-MANAGING.

What you learned in nursing as far as patient care will not exist in the real world. You need to learn quickly how to notice changes and pick up on things when you walk in the room. And pray every day that you can keep your patients safe and pick up on any problem and manage them appropriately.

The schools need to change their curriculum to rapid response treatment and micro management nursing.

Jacobero · Mar 17, 2008

I never timed myself, but we do walking report, and that helps a little to get a first time visual on a patient.

Then, while giving 8 am meds, I listen to lungs, check how much o2 they are on (I work on an adult pulmonary) or do the vent check quick. Glance at the foley, or ask how everything is going with the voiding/bowels, ask about pain, other concerns, how the breathing is going. then look at the ankles/feet.

With the adult alert patient, there's alot you can tell by looking/talking. With someone who's not alert, you'll have to spend more time assessing because you have to find the info. If it's a patent that I know that I'll need to really look at their bottom, I tell the aide to let me know when they are getting to the bath, and assess the back and bottom then. It also helps me participate in their ADL care as well, and the aides like it if nurses can take a quick moment to help with a bath too I also check/flush IV's/central lines/ports on first contact because I want to know first thing if there is a problem.

The more you can combine things, the better and quicker you will be it, but it takes practice. In a few months of practice and doing these things every day, you will be amazed at how much you can accomplish in a 5-10min encounter with a patient.

Spatialized · Mar 17, 2008

First assessment takes about 15 minutes per patient, give or take, including vital signs (yes, we do the VS not our aides). But usually during the VS I can chat with the patient (those who are with it) gathering info like bowel habits, urination, pain, level of orientation etc., so that by the time I'm done with vitals all I have to do is look, listen and feel . I always do a full head-to-toe, no matter why they're in. I like to have a general baseline for my patients. Later on I will do more focused assessments, based on chief complaints etc., like focusing on the groin sites for my angios, lung sounds for the COPDers, everything for the open hearts.

But the assessment starts from the moment I walk in the room, from there on out I'm assessing, seeing what's new, what not.

Cheers,

Tom

deeDawntee, RN · Mar 17, 2008

The above poster said it very well. You learn to combine things as you go and you will start to see that you will have soon have an intuitive sense of what needs to be assessed. When you get report, you will also get a sense what you need to concentrate on. If the nurse said the pt hasn't had a BM in three days and has been nauseous, don't forget to do a thorough bowel exam (sounds, tenderness etc). If she says, he is eating, had a BM today, then bowel assessment isn't a big deal.

My approach is that you don't have to "reinvent the wheel" if each nurse is documenting well, a 1-2 minute assessment is probably all you need. If there is an issue going on, then more frequent, thorough assessments are necessary.

Use your best judgment. A quick head to toe assessment is just that. I like to check the pupils, check grip strength, pulses X4 extremities, cap refill, lung sounds, heart sounds, bowel sounds. How is the urine output, and check your lines(sites) and pumps and how full your fluids are. Skin assessment will come when I do baths unless I heard in report that there is a problem, if that is the case, I will keep that person off their back, and turn side to side until I have time to check out their skin more thoroughly. Remember you have 8 (or 12) hours to do it. Everything does not have to be done in the first few minutes with a patient. Another approach I would recommend, is to do a more thorough assessment on your unstable patients and don't even assess your stable patients until later when you have a bit more time. That way if you need to make doctor calls you can do it sooner rather than later and intervene as quickly as possible.

You will find your own way and your own pace through this. Great question!!

RNperdiem, RN · Mar 17, 2008

I like to do the full head to toe and chart it then and there. I want it all done without having to go back and fill in missing information; that is my personal preference. The assessment takes about 5-10 minutes.

When I had 6 patients as a new med-surg grad, I would chart my last assessment at around 0900. Mornings are interrupted frequently by glucose checks, doctors on rounds, breakfast trays, and patients needing help to the bathroom(after 0600 Lasix takes effect).

BrokenRNheart · Mar 17, 2008

"Everything does not have to be done in the first few minutes with a patient. Another approach I would recommend, is to do a more thorough assessment on your unstable patients and don't even assess your stable patients until later when you have a bit more time."

That is probably a good way to start your days.

Also, get yourself a mental or written checklist so you can learn to do that head-to-toe as routine when you walk in a room. I like to think of it as head of bed to foot of bed. I see if the patient is positioned right, notice a foley or urinal and note quality, facial expression, distress, color. I do listen to lung sounds first thing because you never know when that might become a problem and you want your baseline. My stethescope goes from back side to side to front same to heart and down. You learn to notice a lot very quickly. You are scanning as you are assessing. I look all around and try to pick up on what I can from the top of the bed to the bottom and around. I look at my report sheet before I walk in to remember who I am seeing and what I am assessing.

Think diagnosis and history when you walk in. Think problem oriented and baseline for the rest of the day.

It will come.

leslie :-D · Mar 17, 2008

like others, i'm assessing throughout my visits w/the pt.

i note foley, iv's, monitors, gen'l appearance, ms.

my first focused assessment is r/t the cc, and any accompanying systems it may affect.

then, between the aide and me, i can get all other data.

you will develop your own system, trust me.

it always falls into place.

leslie

medsurgrnco, BSN, RN · Mar 18, 2008

I always do a head-to-toe assessment on all patients which takes 5-10 min per patient, and try to do them near the start of the shift. Patients have frequently told me that my assessments are much more thorough than other nurses so I do not trust the assessments of others. (One patient who had been in the hospital for several days told me no other nurse had done even a brief assessment. Another patient became nervous and thought something was wrong as no other nurse had done a full assessment.) I do the assessment in the same order each time which makes it faster and less likely that I will forget something. I write the O2 level, IV site & IVF, foley, other drains, dressings, etc. on my brains and place a checkmark by them after I've checked them along with any notes for later charting. I then ask questions about pain, nausea, last BM, orientation, etc. If I need help to check the patient's back/butt, I indicate that on my brains and inform the CNA I will need help with that area when they have time to help me. I also check to see when I need to hang IVF so that I can schedule doing that task later.

gardenmum · Mar 18, 2008

I'm struggling with the very same thing. I work nights so I don't feel like I can wait to assess things till later in the shift because my patients are sleeping. Of course I'm usually back in there with 0000 meds and 0600 meds and am doing pain & IV checks regularly. I still feel like I'm rushing through my assessments and am afraid I'm going to miss something. The beginning of the shift continues to be a whirlwind and I cannot wait until I get some sort of system. Any suggestions from night shifters?

I always try to pop in to say hello to my 5-6 patients as soon as I get report. Sometimes I assess them all then pass meds and sometimes I pass meds at the same time I'm assessing. Sometimes I get to my charting and notice something charted regarding skin that I didn't see then I go back in to check again ... LIke the original poster though, I feel like I'm taking too long and falling far behind when the shift is just beginning ...