Health assessment for telemetry unit

[Lev, MSN, RN, NP]

I'm a new nurse. My assessments take too long. Telemetry nurses (or anyone), can you please list everything you assess in order you assess it? I just heard a great tip: check heart, lungs, and bowel one after another. Also, when do you do your assessments? With med passes? Right when you get on the unit?

Thanks,

Lev

[applewhitern, BSN, RN]

We had a completely separate physical assessment class in our BSN program that focused on head-to-toe assessments, so that is usually how I do it. With experience, you will be able to do this quickly. When I first get out of report, I will glance in my rooms to be sure everybody is OK, and that their bed alarms are on, if needed. Then while I am doing meds, IV, etc., I will further assess them. We chart by exception only, so that makes our charting fairly simple. I basically start by looking at their sclera, check pupils, mouth, then work my way down. I try to focus on the reason they are in the hospital. For instance, if they are bedridden and in with CHF, I don't focus on the fact that they have foot-drop; I focus on lungs, heart, edema.

[RNKPCE]

We do bedside overview so I guess a general idea of LOC during this time as well as any special lines or tubes. I check tele monitor and make sure they are in the rhythm I was told they were in during report. Then I start making rounds and do a full assessment. If patient is napping or off unit I may do it during my first med pass. I do LOC, orientation if it isn't apparent or if a neuro check is ordered specifically, feel for radial and pedal pulses and assessing for edema at this time as well as IV sites. Then listen to heart and lungs anteriorly and abdomen, and assess abdomen, have patient turn over and assess lungs posteriorly and check skin for breakdown, on back, heels, ankles, elbows, behind ears if using 02. I check that IV fluid that is hanging is accurate. The assessment doesn't take that long, charting it takes longer. Of course some patient need to be tolieted during this assessment so that can make things take longer but I use the time getting them up to the bathroom to check the skin on their backside and listen to their lungs. I may need help turning a patient to assess their backside so if that's the case I will do what I can and then find help later to assess the back side.

[proud nurse, BSN, RN]

My assessment always consists of heart, lungs, bowels, CRT, pedal pulses, edema, assess IV site, making sure leads are in place if on tele, and LOC. This is what I do for every patient, unless a more focused assessment is needed based on their dx. I work nocs, so I try to do my assessments as soon after the PCA has gotten vitals so I don't keep waking them up. Sometimes that doesn't work because I'm stuck getting report from a long winded PM nurse.