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Quick Head to toe?

Med-Surg   (766 Views 8 Comments)
by NurseTman NurseTman (New Member) New Member

NurseTman works as a Nursing Student.

1 Like; 81 Visitors; 2 Posts

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Hey Experienced Nurses,

I am a med-nurse in NJ in which there are times when we can have 8 patients each. I was wondering if you had tips for doing quick head to toe assessments. The clock runs quick, and I try my best to manage my time. Hope this helps,

 

Tyler M. BSN RN

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retiredmednurse has 36 years experience and works as a Retired RN.

3 Likes; 1,591 Visitors; 63 Posts

What shift do you work? I worked graves and did my assessments in pieces. The VS will give you a lot of information. If surgical, check the dressing(s) for drainage amount, color, smell, and if you need to replace or reinforce. Know the surgeon's and/or hospital preferences of this. Some docs like to do the first dressing change themselves-so just reinforce. Check the IV site and make the right bags are hanging at the proper rate. Check all drainage tubes for amount and color. And I focused on the primary system that the patient is in for. If COPD, the lungs; if stroke, the neuros. If I help the patient up to the bathroom or the BSC, check their skin for color, breakdowns,swelling, and turgor; orientation, their muscle-joint mobility, and their lungs and heart if not already done. At my hospital, it was day shift that was expected to do the main assessment. Patients don't get enough sleep in the hospital, so I tried to disturb them as little as possible. I had a nursing instructor who said you should be able to do a quick assessment in the first 30 seconds you enter the room. (She meant the life-or-death kind.) It is important to watch what needs to be watched, so you don't end up with any major surprises at the end of your shift.

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KellT1203 has 7 years experience and works as a Med/Surg RN.

8 Likes; 5,842 Visitors; 197 Posts

These are my assessment questions, head to toe.

Any headaches, neck aches, neck pain, stiffness? (look for glasses or hearing aids).

CP, shortness of breath, cough, palpitations?

          Look at their breathing, NOTE* sometimes they will say no cough but yet you

         will hear them cough (mostly post surg or pts with lung issues)

When was the last time you had a BM? N/V/C/D? (last episode)

Pain or burning with urination? (asses color of urine, or ask aid if poss)

Falls in the last year? Assistive devices? ( assess extremities, check for edema)

Then ask the patient if you can listen to their innards (I like to be funny)? (listen to heart lungs, abd).

I am constantly assessing every time I look at my patient. Looking around the room. It only takes 5 minutes, maybe more depending on the patient to complete my assessment (charting is MUCH different, but we all know how that goes).

While you are doing their skin assessment (they are walking to the bathroom or turning in bed - look at their back side) look for IV, bruising, wounds, surgical site.

I could easily be asking them while I am doing my med pass. I am not always able to get all of my information at the same time so I rely on frequent contact with the patient. If I don't have part of my assessment complete I at least start charting (when I can) and fill in the blanks later.

I do have an awesome assessment sheet I use that helps me to remember so I don't have to ask the patient again or go back to reassess. We use COWS, so I am able to make notes as I go.  If you would like to check it out let me know. I would be happy to email it to you. You can make changes to it as well, tweak it to your specific needs.

Kelly

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NurseTman works as a Nursing Student.

1 Like; 81 Visitors; 2 Posts

1 hour ago, KellT1203 said:

These are my assessment questions, head to toe.

Any headaches, neck aches, neck pain, stiffness? (look for glasses or hearing aids).

CP, shortness of breath, cough, palpitations?

          Look at their breathing, NOTE* sometimes they will say no cough but yet you

         will hear them cough (mostly post surg or pts with lung issues)

When was the last time you had a BM? N/V/C/D? (last episode)

Pain or burning with urination? (asses color of urine, or ask aid if poss)

Falls in the last year? Assistive devices? ( assess extremities, check for edema)

Then ask the patient if you can listen to their innards (I like to be funny)? (listen to heart lungs, abd).

I am constantly assessing every time I look at my patient. Looking around the room. It only takes 5 minutes, maybe more depending on the patient to complete my assessment (charting is MUCH different, but we all know how that goes).

While you are doing their skin assessment (they are walking to the bathroom or turning in bed - look at their back side) look for IV, bruising, wounds, surgical site.

I could easily be asking them while I am doing my med pass. I am not always able to get all of my information at the same time so I rely on frequent contact with the patient. If I don't have part of my assessment complete I at least start charting (when I can) and fill in the blanks later.

I do have an awesome assessment sheet I use that helps me to remember so I don't have to ask the patient again or go back to reassess. We use COWS, so I am able to make notes as I go.  If you would like to check it out let me know. I would be happy to email it to you. You can make changes to it as well, tweak it to your specific needs.

Kelly

Thanks Kelly, I would love to see that assessment sheet. You can email me at tyler.manzi@yahoo.com. 

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KellT1203 has 7 years experience and works as a Med/Surg RN.

8 Likes; 5,842 Visitors; 197 Posts

Sent!

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Nurse_Celi has 1 years experience.

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Kelly, send it to me?

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IVRUS has 32 years experience and works as a Clinical Infusion Specialist.

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On 1/26/2019 at 1:39 PM, NurseTman said:

Thanks Kelly, I would love to see that assessment sheet. You can email me at tyler.manzi@yahoo.com. 

I love to see what others have found useful, as it greatly helps my students too.. can you sent it to ptec1@hotmail.com? 

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CKPM2RN has 2 years experience and works as a Fire Medic and Urgent Care RN.

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Share this assessment sheet?

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