how to do 5 min assessment

nursemike, ASN, RN · Jan 16, 2008

I suppose you've already heard about counting resps while pretending to take a pulse. If not, it can work, a lot of the time. Spend 30 secs on pulse, then 30 on resps. Assuming both are regular, if not, you need to count for a full minute. But a lot of the time, they are regular.

I work nights, and my facility requires a complete head-to-toe in every 24hr period, performed by an RN. That assessment is usually done at midnight, to set a baseline for the next 24. We also do a head-to-toe at the beginning of the shift (1930-2030, for me--that is, I start a 1930 and try to have them all done no later than 2030). I try to do a thorough assessment, including skin checks, on my first round. If nothing is out-of-the-ordinary, I feel safe not rolling them around at midnight, though I still check for incontinence, if appropriate. At 0400, I do a focal assessment, which (on my unit) always includes neuro checks. But my 0400 neuros don't necessarily include name, rank, and serial number (person/place/time)--I ask about pain, and whether they need anything, stuff like that. I also tend to skip the penlight in the eyes at 0400, as long as I can see that their pupils are still equal and round.

Speed comes with practice. I have had nights when I had to assess one system at a time, between minor emergencies like putting people back to bed, and stitch them all together for a note. Sometimes, too, you can get in a little assessment along with other tasks, like med passes or dressing changes. If a patient is AOX3 for 2200 meds, he's probably Ox3 at midnight, even if he isn't so A. Of course, that can depend some on the meds, too.

I think this is one place where the "art" of nursing really comes into play. Sometimes, even though a patient gets all orientation questions right, you get a sense that their mental status is a little different. Are they just sleepy, or grumpy, or dopey? Do I need to call the doc? Am I Snow White? Maybe I'm the one with mental status changes...

keishapound · Jan 16, 2008

thanks nursemike and I will use your tips

EmmaG, RN · Jan 17, 2008

Sometimes, even though a patient gets all orientation questions right, you get a sense that their mental status is a little different. Are they just sleepy, or grumpy, or dopey? Do I need to call the doc? Am I Snow White? Maybe I'm the one with mental status changes...

Yeah, they can be oriented but inappropriate. "It's Thursday, January 17th, I had surgery on Tuesday and I'm in ___ hospital... now go downstairs and let the cat in before you lock up."

Then again, I've been known to ask a patient the day and/or date and then ever-so-gently tell them they're wrong--- only to find out I'M the one who's mixed up.

I blame it on night shift. At least I hope that's the cause... but that's my story and I'm stickin' to it.

Virgo_RN, BSN, RN · Jan 19, 2008

I count respirations while auscultating heart sounds. 99.9% of my patients do not speak while I'm listening to their chest.

EmmaG, RN · Jan 19, 2008

I count respirations while auscultating heart sounds. 99.9% of my patients do not speak while I'm listening to their chest.

That's weird. 99% of mine start to chatter away once I place the stethoscope in my ears...

:stone

Virgo_RN, BSN, RN · Jan 19, 2008

:chuckle

I get that every great once in a while.

eager1hasbegun · Jan 19, 2008

If they are sitting up, you can rest your hand on their shoulder while you take the pulse to also help you feel resps. I figured that out during a psych rotation. My pt had Parkinsons and couldn't keep still. Resting my hand there not only helped me to assess his breathing, but also seemed to have a calming effect on this worked up guy.

paxpax · Jan 20, 2008

That's weird. 99% of mine start to chatter away once I place the stethoscope in my ears...
:stone

Same thing happens to me!

:mnnnrsngrk: