Overnight Assessments

[mrsamjones]

Hi all! I will be changing my shift work from 7p-7a to 11p-7a. My question is, anyone that works this shift, when do you do your assessment? My thoughts were, if I am given a timely report (perfect world nursing) I would attempt to do my initial assessment with 0000 vital signs. If I do not get a timely report, I was going to write a brief note for each patient detailing that I assumed care of the patient, the patient is stable but sleeping (if stable) and that I would chart my assessment with whatever med pass was due next. Of course if the patient I received report on appeared to be at risk of complications or appeared unstable, I would wake them and do an immediate assessment i.e. post ops, respiratory problems etc.

What is everyone's practice for the 8 hour overnight shift? Thanks!

[Here.I.Stand, BSN, RN]

I got everything done in that first 0000 rounds -- VS, assessments, meds, etc. Honestly I wouldn't take the time to write a note saying that you just assumed care and will assess later. 1) your time could be better spent, and 2) you don't know if they're stable or not until you assess them. Even if you just heard in report that they were all stable, you don't want to document something as fact when you did not see it yourself.

[blondy2061h, MSN, RN]

How many patients do you typically have? You could do their vitals yourself to ensure you're able to get your assement, vitals, and midnight meds all done together. When I worked 11-7 I would sneak in and make my presence known without turning the light on, and do as least disruptive of an assessment as possible, listening to heart and lung sounds and assessing ankle edema by touch in the dark in whatever position they were in. Then I would ask them to call me next time they used the bathroom so I could assess neuro and skin.

[mrsamjones]

I guess I should have clarified, we typical do a bedside report on our patients in which I am able to do a quick once over. You can typical tell if the patient is stable at this point. That is why I felt comfortable writing that in a note; however, you are right in that it would be extra time to write that.

[mrsamjones]

I work on a MSP unit and we typical have at least 6 if not seven patient. I very much rely on my CNAs for VSS normally during the 12 shift. Maybe doing 8 hours, I will have the opportunity to do them myself and assess the patients.

Thanks for the response.