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!

[evolvingrn, BSN, RN]

I work acute care and I generally do a head to toe assessment on every pt in my care. Our pts are surgical so the pas and surgeons do a focused clinical assessment.

[evolvingrn, BSN, RN]

To the op ......you 2 weeks into your education.....quit overthinking what you will and won't need.

[Lemon Bars]

Asclepius86 said:

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.

Thank you for your reply and the attached Guide. I will study the assessment guide. ?

[Hoosier_RN, MSN]

Lemon Bars said:

This is as I feared. Another long series of classes where I will intensely study everything only to find that only a small fraction of what I learn will be applicable to my job. (Just like statistics, chemistry, even large portions of anatomy where we were forced to memorize the name for every curve, protrusion and groove in every bone...) Sigh...I will learn as much as I can and hope it comes in handy some day.

It will, for NCLEX at the very least

[Horseshoe, BSN, RN]

Lemon Bars said:

This is as I feared. Another long series of classes where I will intensely study everything only to find that only a small fraction of what I learn will be applicable to my job. (Just like statistics, chemistry, even large portions of anatomy where we were forced to memorize the name for every curve, protrusion and groove in every bone...) Sigh...I will learn as much as I can and hope it comes in handy some day.

Okay, so what do you think SHOULD be the strategy of the nursing school?

Nurses use ALL of the things you are learning-not all of them every day by every nurse, but nurses in every specialty are using these assessments in their practice. The nursing school doesn't know which specialties a given class is going to end up in. They SHOULD be teaching all of this so that the future ortho nurse knows her stuff and the future neuro nurse can utilize the proper assessment techniques for her patients, the cardiac nurse knows her S2s from her S3s, etc.

If they didn't teach the comprehensive assessment, we'd be reading even more threads about how clueless the new nurses are. "They should have learned how to assess this in nursing school! What are these schools teaching theses students these days?!?!"

[RescueNinjaKy]

You need to go shadow a nurse. You seem to have entered this field with very little knowledge of what actually goes on. You are overthinking about many things. You are still a student, a fairly new student, so you need to relax and see what else they teach you. You mentioned assessing diagnosing planning intervening and evaluating in a separate thread being the realm of the doctors but if you wait and read or listen to your professors you will learn that it is part of the nursing process. Please, take a breath, go shadow a nurse and find out what this profession entails. You need to learn how to walk before you run.

[MPKH, BSN, RN]

I work internal medicine and I do a basic head to toe assessment on all my patients at the beginning of each shift. I'll do focused assessments on areas that are of concern to me throughout my shift.

You might not need to do a full in depth head to toe assessment everyday, but you will use bits and pieces from it in your practice. And you know, nobody is stopping you from doing an in depth thorough full head to toe assessment on all your patients.

Oh and? If you're finding what you're learning as useless, then please re-examine your perception.

[bgxyrnf, MSN, RN]

Lemon Bars said:

This is as I feared. Another long series of classes where I will intensely study everything only to find that only a small fraction of what I learn will be applicable to my job. (Just like statistics, chemistry, even large portions of anatomy where we were forced to memorize the name for every curve, protrusion and groove in every bone...) Sigh...I will learn as much as I can and hope it comes in handy some day.

In every field, a substantial portion of what is taught is for completeness, to provide a solid underpinning from which to launch specialized study, and to provide the context and vocabulary to permit interdisciplinary communication at a professional level.

In each course of study, there is also a sizable percentage of students who want to be taught the bare minimum of "what's on the test" or what is directly applicable to their limited vision of what they expect to "need."

[Here.I.Stand, BSN, RN]

The times I had the most in-depth health histories taken were as a new pt in OB and neuro clinics. They were done by the MD or NP.

My health histories in my ICU is very basic -- drug allergies, known exposure to MDROs, recent travel, TB sx, current on flu vac, do they have an advance directive, baselines (e.g. does your BP always run 90/40?), LMP for women of childbearing age, etc. When the pt is in my ICU because he was hit by a train, honestly I don't care if his maternal great grandmother died of an MI at age 63 and 3.5 months. But, how would I know how to do the above if I hadn't been taught?

You won't ever do every assessment on every pt. Would you check pupils or cough/gag reflexes on an a&o pulmonary pt? Would you ever do a fundal check on a 90 yr old? Of course not, because that would be foolish and demonstrare a huge lack of thinking.

In the ICU we do a standard head-to-toe q 4 hrs, and focused assessments as appropriate. It might mean as often as neuro checks q 15 minutes x2 hrs, 30 min x6 hrs, and then hourly. In ED it's all focused assessments. In LTC it might be a full head-to-toe once a week, once a month, etc. In public health RNs assess communities or populations, as opposed to individuals.

Your instructors don't know who will end up working home health or helicopter, 22 week preemies or geriatrics, etc. That's why they teach everything.

My assessment instructor made another good point: we really don't ever need to do percussion over the lungs if we work in acute care. We have portable chest x-rays that can definitively show consolidations. But if we decided to volunteer for a medical mission/humanitarian org in a rural area of a 3rd world country, percussion would be very important to know how to do.

[Karou]

Lemon Bars said:

This is as I feared. Another long series of classes where I will intensely study everything only to find that only a small fraction of what I learn will be applicable to my job. (Just like statistics, chemistry, even large portions of anatomy where we were forced to memorize the name for every curve, protrusion and groove in every bone...) Sigh...I will learn as much as I can and hope it comes in handy some day.

Please don't have this attitude. Learning how to do an assessment is a critical nursing skill. Depending on what speciality/area you go in to, you will find yourself losing certain skills and relying on others. That doesn't mean you don't need to know the basic idea of how to do an assessment if something unusual pops up.

I work adult med surg. Once in a blue moon we get a pediatric patient. About once every 6 months we get a pregnant woman. Each time I have to reach back in my knowledge and remember what I know about these patients, because these are not my norm. Same true if we happen to get a hip/knee, women's surgical, or neuro patient (none of which we usually get). You will always have a chance of getting "overflow" specialty patients, or being floated to a speciality department.

As for your original question- the most thorough assessment I do is on admission. Head to toe, to butt cheeks and between those toes. I am so fast though, that an observer may not see everything I am doing or realize how thorough I am. I couldn't have developed a fast way to do this if it weren't for my basic knowledge I was thought in school. When necessary, I focus on one body part over the other (the complaining/problem area). This takes me around 30 minutes including med rec, history, ect (all of the required facility charting). I do my focused shift assessment in less than 5 minutes on each patient. I am also constantly assessing my patients throughout the shift, though they usually don't realize this.

As for not using an otoscope... I had to do that recently!!! You never know what skills you will need on a given day.

ICU nurses do the most in depth assessments, my guess.

[BeachsideRN, ASN]

Nurses are constantly assessing their patient in some way or another every time they enter the room.

Research nurses get very, very detailed information about their patients at every visit and the visits I have seen typically last 1-6 hours depending on the scope of the trial.

[sommer0515]

We perform "focused assessments" in my hospital (I work a telemetry floor) but I always start out with the ABCs.. Lung sounds, pulses, circulation (edema), etc... If they're post cath: groin site/ pedal pulses... It's all focused on what the general diagnosis is. New admits usually get a more detailed assessment.