In what setting does an RN do the most thorough physical assessments and health histories?

[Lemon Bars]

Please share your knowledge experienced nurses!

I am two weeks into a BSN program and I am enjoying it. We are learning, or at least being exposed to, the taking of fairly detailed health histories and also somewhat detailed physical exams, of the sort I previously thought were only done by an MD, DO, PA or NP. For example the textbook says, "When performing a sports physical or evaluation for work..." Personally I have only had this type of assessment done on me by a clinician, never a nurse, but I have already been told in a previous thread that I have underestimated the scope of nursing practice. I do understand that nurses round on their patients in the hospital to assess vital signs, wounds, pain and tolerance of medications. I know very little about the intake and discharge process at a hospital.

My work experience includes night shift in a hospital as a nurse aide and also as a scribe in a primary care clinic. In my admittedly limited experience, I have never seen a non-NP nurse perform these tasks. Don't get me wrong, I love learning about this stuff! I just thought that a nurse would have to go on to NP school to do these types of assessments.

My question is this: In which settings are these types of assessments (which to me seem "higher level") performed by a non-NP RN? Home health visits? Triage at the ER prior to a patient being seen by a clinician? Intake or discharge from hospital or surgery center? Skilled nursing facilities? A routine check-up at a specialist doctor's office? A visit with a Coumadin nurse? A clinic inside a prison when the MD is not available that day? A college campus? A rural clinic? Public Health outreach?

I know it's very early in my career, but I would like to steer some of my education and thinking towards RN careers where I could talk with patients and do these types of assessments routinely. Preferably, my patients would be conscious (not sedated in ICU or OR). Please keep in mind that I am a student. I may misuse terms or phrases like triage, discharge or high level assessment, so please consider the spirit of what I am inquiring about. (I misused the term 'provider' awhile back in a previous thread and caught heck for it.)

I'm the type of person who likes to look ahead to see where I'm going career-wise, because I've taken a few wrong turns in the past and wasted some time and money. I'm so sorry for the long post. Thank you if you read all that!

[KelRN215, BSN, RN]

Is there a reason why you think nurses do not fall under the umbrella of "clinicians"?

All RNs perform comprehensive assessments.

[klone, MSN, RN]

I spend about 30 minutes doing a health history on women in their entry to prenatal care.

[SmilingBluEyes]

I think you are not clear on what you are asking. It's about FOCUS. We ALL perform thorough assessments, but they may vary by SPECIALTY. We focus on varying systems based on our specialties and what is the focus. And it's not a one-time thing. We are continually assessing and re-assessing our patients throughout their stay, or in my case their treatment, in dialysis.

[JBudd, MSN]

Many times nurses are the ones who spend the most time getting histories, and we all do head to toe assessments pretty much every shift (or should anyhow) in hospital.

Much of what you are learning doesn't all get done on every patient every time. But you are learning how to do indepth on every system, so if you have a patient with resp problems you can get a good resp history and assessment, while doing a shorter one on the other systems.

[Lemon Bars]

In my mind a clinician is someone who makes a diagnosis and prescribes a treatment, so I suppose nurse do meet this definition. However, at the clinic where I work, doctors, physician assistants and nurse practitioners are referred to as part of the clinical staff, whereas RNs, LVNs and medical assistants are referred to as the nursing staff. I tend to think of a clinician as someone who can make a medical diagnosis and prescribe a drug, but perhaps that is just because of the setting I work in?

[Lemon Bars]

Ah, so JBudd you are saying that a head to toe assessment of each patient by their nurse is common at the start of every nursing shift? I never observed this as a nurse aide - I suppose I was too busy rushing around gathering vital signs and toileting patients.

And klone you are saying you do a detailed healthy history when a new patient enters prenatal care. I see.

[Tweety, BSN, RN]

Lemon Bars said:

Ah, so JBudd you are saying that a head to toe assessment of each patient by their nurse is common at the start of every nursing shift? I never observed this as a nurse aide - I suppose I was too busy rushing around gathering vital signs and toileting patients.

And klone you are saying you do a detailed healthy history when a new patient enters prenatal care. I see.

Assessments by hospital nurses are ongoing and not necessarily at the beginning of the shift. As was stated hospital floor nurses will focus on what they need to. I work ortho and I'll focus on the extremity but also listen to the lungs and belly for complications. I won't drag out a penlight and check their pupils if they are alert and oriented. Also if they are a walkie-talkie, I'm not going to make them turn over to check their sacrum. Throughout the day we're observing our patients, assessing vitals, etc. I'm sure the nurses in the hospital you worked at did this sort of thing.

Also, when a patient is admitted we take a history, or in my case the patients that are admitted to the pre-op unit have this done, but I review their history.

We're prescribers of nursing treatments, but not medications. We are smart enough to recognize when a patient needs a medication, say like a diuretic, or a procedure like an EKG when they are complaining of chest pain, but we operate under the direction of a doctor/NP/PA that can prescribe what we recommend. It's a collaborative thing.

All that said, the assessments and physicals you learn to do in your BSN program aren't always the reality for the practicing RN...but you need to know how to do it all in order to focus. You need to be able to get out that otoscope and check out a complaint your patient might have, you need to know those heart sounds, lung sounds, how to do a good neuro assessment on someone with mental status changes during your shift, etc.

Good luck.

[Hoosier_RN, MSN]

In ltc, we have no one else to depend on. Skilled is a daily assessment, and open concerns are shift assessments. So all specialties do assessments that should be in depth for that specialty

[MurseJJ]

I'm a senior BSN student and I attached a head to toe assessment guide one of my professors gave to us to help guide our assessment in our Med/Surg II clinical rotation (most of us are in critical care units, I'm in a cardiothoracic ICU). I think you'll find that as you progress in your nursing education, you'll see that yes, nurses are performing many types of physical assessments and taking detailed health histories, tailored to the patients they take care of and the settings they practice in.

An_Easy_Guide_to_Head_to_Toe_Assessment_-2.pdf

[MurseJJ]

Lemon Bars said:

In my mind a clinician is someone who makes a diagnosis and prescribes a treatment, so I suppose nurse do meet this definition. However, at the clinic where I work, doctors, physician assistants and nurse practitioners are referred to as part of the clinical staff, whereas RNs, LVNs and medical assistants are referred to as the nursing staff. I tend to think of a clinician as someone who can make a medical diagnosis and prescribe a drug, but perhaps that is just because of the setting I work in?

I think the general view is that nurses are professional clinicians, who do assess, diagnose (nursing diagnosis), make a plan of care, treat, and evaluate the efficacy of treatments, within their scope of practice. All of this is of course based on an understanding of anatomy, physiology, pathophysiology, pharmacology, and clinical nursing sciences/management.

Health professionals such as physicians, nurse practitioners, and physician assistants are often referred to as the "providers", who make medical diagnoses and prescribe medical treatments/medications. MDs/DOs, NPs, PAs, and nurses are all clinicians.

[Julius Seizure]

I remember all the assessment stuff I was taught in school, and no - I dont use it all in my daily assessments. Our assessment class included things like looking in the ear canal and a thorough cranial nerve exam as well as assessing gait,balance, posture. It included checking several reflexes, too. I even learned percussion of the chest and abdomen to assess liver size and other organ systems. I've NEVER assessed someone in the real world by percussion and I've never seen anyone else do it, either.

But as part of an ongoing assessment that has become just part of my thought process...I do notice if their gait or posture is off, and things like that. Some of the stuff becomes just part of your brain and you dont assess it *intentionally* but you do watch it as part of your 12 hour shift of caring for that patient. Some of it you almost never use.