Morning assessments/charting/time mgt

  1. Hello!

    I am a new nurse on a med-surg floor. I am trying to figure out when to do assessments and chart them. I know this seems simple, but I am going to be honest without trying to be critical - most nurses I have followed do not assess. They do a simple assessment (talk to patient, touch skin, MAYBE check feet for edema) but they usually do not check lung sounds, heart sounds, skin, pulses, etc. So, when I go to do assessment I feel rather dumb. Plus, I feel like I am waking the patients up and that makes them dislike me upfront.

    So, I understand that I am not going to do a complete head to toe assessment with neuro check, etc on every single patient every single day. . .however, I do have a flow sheet to chart and I am not going to chart something (breath soundes, heart sounds, skin) without directly observing it myself. So many nurses just look what the nurse the day before checked.

    What do you do immediately after receiving report? Do you do all your assessments at once in the morning before giving meds? Do you do a total assessment on everyone?

    All advice is gratefully taken - thank you so much.

    New Nurse (just passed my NCLEX today
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    About Lola77

    Joined: Feb '09; Posts: 104; Likes: 222
    RN; from US
    Specialty: Neuro/Med-Surg


  3. by   Ayvah
    congrats on passing your NCLEX! Here's what I do. After I get report I check labs for problems and check tele, then I do an assessment coupled with meds. If a patient is sleeping it depends on your day and your preference, if you want to move to another patient or wake that patient. If you move onto another patient, you'll just wake your first patient at the end. Definitely do meds and assessment together if you aren't currently.

    I agree that it is frustrating when nurses don't do basic assessments on their patients. What I do at minimum on every patient is:
    -ask about their pain level and location
    -listen in x4 places lungs (upper and lower), and x1-2 places heart for irregularity/etc unless they have a heart condition, and then I'll be more extensive. I've had patients who look like they are breathing fine but then when I listen I've at times been surprised to hear their lungs aren't that great, and that's important to know. Also, checking lung sounds gives a convenient opportunity to check the skin
    -ask about last BM. If OK, listen to bowel sounds on both sides. If not OK, or if a surgical patient, I'll listen x4 places
    -look at ankles and press on them to check for edema.
    -check oxygen amount, tele box #, what IV/TF is running and what rate, and glance at the IV site to ensure it looks OK.
    -assessment specific to diagnosis
    -ask pt name and birthday for meds.

    don't feel bad about waking the patients, you need to make sure they are OK. You never know too if that sleeping patient is really hypoglycemic! You need to get a baseline assessment to make sure the patient doesn't need immediate intervention. You know the saying, all the codes are at shift change!
    good luck!
  4. by   Kittyfeet
    Honestly, I'm still a new nurse (3 months so far on Telemetry floor) and I'm still trying to work this out for myself. I am still kind of slow and I would also appreciate any advice on how to assess fast, but thoroughly. Right after I give report I go check on all my patients, cause I have realized you don't really know how long it has been since someone was in that room last to check on them. I try to check as much as I can right then and then if I missed something try to finish it up during the med pass. I try to see if they need more fluids, a new IV or any prn meds during that initial visit so I'm not running back and forth.

    The things I make sure I get for my assessment are pain, orientation level, lung/heart/bowel sounds, Tele box #, ankles/feet circulation, I check IV and hands/arms/nailbeds/skin quality all pretty much at the same time and I try to get each patient to squeeze my hands and press against my hands with their feet because we seem to have a lot of post CVA with one sided residual people. Then I try to focus on their Dx, a wound, or post op site, if they have an NG or foley, etc. and on unable to turn/total cares I try to go in with the tech for the bath to help if they let me know when they are doing it so I can take a good look at the back without having to get the patient up over, or I do their Q2hr turn and look but a lot of the patients are too big for me to move alone.

    Sometimes I get all of this during multiple visits and I just jot notes down on my report sheet for abnormals I need to chart on.

    One of the nurses told me I should chart the assessment in the room while I'm seeing the patient at the beginning of the shift which is what our hospital pretty much wants us to do but I'm just not fast enough yet! I'm worried I'm falling into bad habits though, back charting :/ I need some tips too! But I just can't feel good about skipping anything on my assessment or copying the last shifts notes. I hear you on that. I have seen wrong info copied like 5 times.

    Good luck and congrats on passing your NCLEX! Get ready for a lot of personal growth... I can't believe how much my confidence has gone up in 3 months even though I have a long, long way to go.
  5. by   nurseme3
    This is my general assessment for all my pts, obviously spending more time on "problem" areas as needed:

    1. Introduce myself, ask if they have pain and where
    2. Vital signs (by hand! you gotta know feel and hear what is going on!)
    3. Listen to heart (is it regular rhythm, audible)
    4. Listen to lungs (top and bottom of each lung)
    5. Listen for bowel sounds and look for abdominal distension
    6. Feel for pedal pulses and check for edema
    7. Look at all dressings to make sure they are CDI
    8. Make sure all tubes are connected and running at right level (suction, rate, etc)
    9. Flush / assess IV if applicable
    10. Promise to return with pain meds or whatever else they need

    Hope this helps!
  6. by   SRRIII
    After report I go in to see all my patients which is around 0730. First I introduce myself and ask about pain level. Then make sure all their IV, O2 etc is on correctly. I inform patient I will return to do an assessment after I make sure everyone is ok. After I confirm my patients are fine, I check meds ordered to be passed out at 0800 (look at MD orders in chart with MAR). After meds I do assessments and write everything in my form at bedside. I chart when done with all meds and patient assessments.
  7. by   RockyCreek
    Okay, I admit it has been a long time since I worked morning shift! I remember my first trip into the room was just to make sure the patient is alive [yep, it's happened!], introduce myself, and set them up for breakfast [wash rag, tooth paste/tooth brush/ water, TEETH!] If I know what is happening [tests, labs, surgery,etc.] I tell them and then we plan the day together -- will they get in the chair for breakfast/lunch, will they walk the hall, will they get a dressing change, etc. Anyone that doesn't look 'right' is given the immediate assessment; the rest are done as I can in the fastest, most efficient way possible with all the 'stuff' that happens first thing in the morning. I usually have an assessment done in the first 1-2 hours but I might not chart it until all the commotion settles. My motto has always been "People first - paper second" and it hasn't hurt me so far. Of course, I try to make sure the aides gets the vitals on the flowsheet as soon as possible so that they don't 'forget' until the end of the shift to tell me Mrs. Smith has a BP of 200/150 [yep, it's happened!].

    After 20+ years of nursing, day shift is STILL my least favorite shift. I worked 7p - 7a for many, many years and now I work 3p - 11p [my favorite by far!]
  8. by   mcknis

    First of all, congratulations on passing boards! That is definitely something to be proud of and never forget that. As far as assessments go, it is very upsetting to see a nurse chart a complete assessment on a patient based on someone elses assessment, all while not looking once at the patient. It is imperative that you perform a complete basic assessment on every pt you have, and if they don't want to wake up because they are 'tired,' then they should have thought intently about coming to the hospital. I allow patients to sleep throughout the day, or through a meal if they choose, as long as I have already assessed them and can assure they are stable! As the others have already stated, I at least check lung sounds in four areas (if there are any adventitious lung sounds, I check six areas). If they can sit up ok, or at least turn to one side, then I will listen to post sounds. If they can not, then, depending on the patient, I will wait until we get them up for breakfast/bath/bathroom/etc. or will go get another staff member to help me sit them up for an adequate assessment. Listen to bowel sounds on both sides. check edema, check neuro via grips/push/pull/smile/stick out tongue/alertness and orientation (this is more in depth if dealing with a CVA patient).

    All of my assessments are geared towards the diagnosis made and are patient specific. Assessments dont need to last 10 minutes and you have not enough time in the day to do that. I would love to chart at the bedside; however, the charting system at our facility is very lengthy and time consuming. With our current system (LastWord), to chart assessments on 6 pts, I need approximately 45 minutes to chart my assessments. If all 6 of them are healthy without any problems noted on their assessment. I could complete that in about 20-25 minutes. Not always feasible.

    Good luck in nursing and congratulation on becoming an RN!
  9. by   OldnurseRN
    Wow! To be able to chart on 6 patients in 20-25 minutes would be heaven. We use CPSI and if you have 4-5 patients then you have at least half your 12-hour shift in front of a computer. You've got your assessment, your MAR, pain scale with follow up, (follow up on MAR, also), address every goal on care plan, chart on every detail on the Medact, and your patient education flow chart. Then there is the neb treatment you may do. That is charted in 2 places. Same with EKGs. I swear more time is dedicated to charting than patient care. We have no CNA, no secretary, and basically no other persons in our hospital except the 3 nurses on our overnight shift (only 2 if census is low). We cover the ED and have to call the physician, lab, and radiology to come in for them. I think I'm in the wrong place, lol. The most insulting of all this is the day staff always thinks the night staff has nothing to do, though we fill water jugs, empty foleys, NGs, change diapers, et al. I've never figured that out since we do the same things they do without the CNA and secretary, RT etc. Our hospital requires we chart on each patient every hour. Still, I pride myself for the excellent care I provide.
  10. by   OldnurseRN
    I neglected to add one last thing, most of our patient rooms don't have bathrooms, lol, so it's commodes or bedpans, carried down the hall to the dirty utility room. The rooms that DO have a bathroom have one too small to even get a walker into.
  11. by   HappydayRn
    I grab labs and med times on my pts. before report. I then do a full assessment on my pts. I may or may not check skin depends on the pt. but I always listen to everything. Sometimes you do forget the little stuff and if it's not critical I save it for later. One thing I don't regulary check would be things like cap refill unless it's a cardiac pt. or some h/x indicates.
    We use computer charting so I try to chart in the room. I work night shift so I get the grumps as well, but hey I'm just trying to do my job here!

    I'll usually assess the pt who I don't know or who is most fragile first and then work my way down the list.
  12. by   SeattleKid09
    If there is someone that I know is going to be upset being woken up I will save them for last as long as I know they're ok. When I do need to wake someone up I still have to consciously remind myself "This is not a hotel." Yes, sleep is important in the healing process however adequate respirations/circulation/etc is slightly more important.

    When I first started med-surg someone suggested I do an assessment, chart it, and then begin my next assessment. It has yet to happen. I simply cannot bring myself to chart when I know there are patients needs that are unmet. If my assessment is not charted until 2-3 hours later because I'm busy with actual patient care...well, that's just the way it goes. Patients come before paperwork. If you find you're playing catch up with charting, make sure you take a moment to write down a quick review of your assessment - three hours later they have all run together!