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!

[Elvish, BSN, DNP, RN, NP]

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We were taught some advanced assessment technique such as percussion, deep palpation, and assessment of reflexes in school but these are skills I have probably never used as an RN. They are more likely to be used by an advanced practice nurse.

I definitely use percussion. I'm in NP school and I percuss my patients if they come in with a bellyache, respiratory infection, or during a PE.

Not only tells me where liver border is, but a pt may come in with what sounds like a URI until you percuss the abdomen and find splenomegaly. Not going to palpate first, because an iatrogenic ruptured spleen on a mono pt. is not something I want to go to court for.

[joanna73, BSN, RN]

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?

Nurses are widely referred to as clinicians. Your definition of a clinician will expand as you continue your studies.

My role is an educator, and my title is clinical educator, for example. In addition, the nursing staff working the floors are referred to as "nurse clinician".

Also, as others have mentioned, you learn the basic head to toe assessment at school. Depending on your work setting, the assessment is then tailored/ focused.

[NTICURN]

So, I've been a nurse for 9 years, and have worked in just about every Hospital setting there is except for Peds ICU and the OR (I'm sure there are more, but those are the big ones I can think of off the top of my head) from OB/L&D, ER (adult and PEDS), ICU (several specialties), specialty and general med surgery floors, Peds inpatient, NICU, PACU, inpatient psych... (I think you get the picture)

And I currently work in a level 1 neuro/trauma ICU. By far, the most frequent and thorough assessments are performed in an ICU setting, because they are the highest acuity. That's not that nurses in other settings are not performing valuable assessments. I may be incorrect in my conclusion, but it sounds as though you are referring more to an initial history and physical assessment...? The ER does a high volume of that type of assessment, but they are brief and focused assessments. Admit (intake) nurses in a day surgery or anbulatory surgery unit do a high volume of assessments, however oftentimes the history portion is done over the phone. So, what you need to decide, is not which specialty does the most assessments, but which type of assessment it is that YOU want to do. I found my niche in ICU, so I'm obviously biased , but you are guaranteed that no matter what field you go into, you will be utilizing (and perfecting) your assessment skills. :) Good luck to you!

[NTICURN]

And not all patients in the ICU are sedated. Some are awake and alert. ?

I think you'd be surprised...I never thought ICU was something I'd like (I thought I wanted to be a labor and delivery nurse.)

Just keep your options open, is all I'm saying ?

[DatMurse]

Julia77 said:

While I agree that shadowing an RN is an excellent idea, to learn more about the RN role, I find that many RN's are unable to clearly articulate what they are doing and why they are doing it to a new learner. Some of this is related to pace -- a staff nurse usually is very busy and cannot efficiently summarize years of study and experience while continuing to manage a full patient load. When I was a new RN, I expected my RN preceptors to be able to provide well-thought out, clearly articulated answers to my questions, but later found that watching RN's with time management and prioritization and researching questions at home on procedures, medications, disease, etc., was more helpful. Some RN's are committed to continuing education, and other RN's, from what I observe, seem less aware and dedicated to this aspect of nursing practice. I feel you will get more joy from your chosen path if you continue to invest time and energy in your learning, even if it doesn't seem so applicable. All the best. Julia

Ageed, many nurses never question there practice and just follow. They dont know that rationale and report what they are supposed to report. Now as long as they do their job that is fine. But when I started working or doing clinical studies a few years ago, I was always paired up with a preceptor who likes students. Clearly one who likes to teach. So I had this idea that every nurses knew every little thing. In reality many dont.

Ex. People are worried about blowing iv lines on a generally healthy person due to rate. Or doing 1l of fluid over an hour.

Fluid overload with complications will not happen over 1l on someone with solid tumor and no complications in their kidney function.

OR even the iv blowing, product specs say these can handle 18l an hour. These are not the first Iv catheters made. We changed the technology for a reason.

But not all nurses know that....