How often do you assess your patients?

seanpdent, ADN, BSN, MSN, APRN, NP · Oct 12, 2008

At minimal, standard is q4hr, but with more critical patients it can be every hour due to the injury(s).- Like our TBI-head protocol patients.

CraigB-RN, MSN, RN · Oct 12, 2008

Just a poll - and I do mean ICU pt assessments. I've been places where it was q2, some where it was q4, some where it was once a shift and then q2-q4 "unchanged" check boxes. Currently my facility's policy is q4 head to toe, with no option for "unchanged." I was at a facility that explained "JCAHO doesn't stipulate how often assessments have to be done, just that they are done head-to-toe once a shift and any changes in condition are accurately documented..the rest is up to the facility." Not sure as to the accuracy of that, but just wondering what different policies there were out there, and which ones perhaps you favor more..more frequent or less frequent...charting-wise, that is.

1. Response to treatement constantly

2. Focuses assessment qhr

3. Complete assessment q4

4. Shared assssment (shift change) q12

5. AS NEEDED depending on what's happening to my patient

Creamsoda, ASN, RN · Oct 12, 2008

Total assesmnt Q4h. Sometimes its qshift, if the pt, is chronic and has been there a while and not much is going on. Obviously assess prn as well.

For a fresh neuro case..often pupils/GCS is q 1h for a while as well, but the rest can be Q4h.

Critical_Care_RN · Oct 13, 2008

Our facility only requires documentation of full head to toe assessment on ICU patients twice each shift(at the beginning of shift and halfway through the shift). However, we are required to document on every patient every 2 hrs and when any changes in condition occur. I have to say though that for most of us, it depends on the condition of the patient. If the patient is really critical, we document a lot more. If the patient is pretty stable, you can cover everything with documenting the 2 full assessments, q2h focused, with changes/interventions documented when they occur.

nrsang97, BSN, RN · Oct 14, 2008

In neuro ICU we do q4h head to toe, and q1h pupils/LOC/motor strength unless written otherwise.

TStewartfan · Oct 14, 2008

Our head to toe assessments are done Q4 hours. If a new neuro pt its Q1 and of course we eyeball our patients every hour to record vitals, urine output etc. Sometimes the docs want other certain assesments done on a regular basis such as CVP, GCS etc. We don't have computer charting so everything we do has to be hand written, can take up LOTS of space....... we have every pt you could ever have, neuro, trauma, cardiac, GI, respiratory etc. Right now we have three quadraplegics on our unit and not one of them has insurance.... and one has been there for 10 months....

Jodi

wanderlust99 · Oct 16, 2008

in my experience, we must chart a head to toe q4hrs. If it's a neuro pt, you do q1hr neuro checks, unless ordered otherwise.

nursecass · Oct 16, 2008

We are required to chart one full head to toe, then changes Q2 hrs (and we actually can get away with "assessment unchanged" q2-I've seen many people do it). I tend to do a full head to toe q4 hrs on my "stable" people with a focused q2. And as someone said, the more critical, the more frequent-it entirely depends why they are there, what their status is, and what types of interventions are going on.

jengga · Oct 19, 2008

In our unit, q4h or twice per shift is the norm for head-to-toe assessment. PRN for changes. For neuro patients, q1h for head chart.

RNperdiem, RN · Oct 20, 2008

Unless a patient is unstable it is Q4 hrs for the full head to toe. Flap pulse checks for plastic surgery patients are assesed hourly. Neuro checks are also more frequent.

tryingtohaveitall · Oct 20, 2008

In our PICU it's a full head-to-toe assessment at least every 2 hours, every hour if they're unstable or have a strong potential to become unstable.