I'm an RN, now FNP x 5 years with over 15 years of ER/CCU and ICU experience. Is it old fashioned to expect RNs to do a full assessment at the beginning of their shift?
I have a colleague/NP friend who has been in the hospital now x 1 week. I will spare the details, but she was admitted, discharged, admitted urgently to another hospital and then transferred back to the original hospital. In her whole WEEK of admission, she says just ONE RN and one MD even put a stethoscope to her back. A pleural effusion was MISSED because no one did this basic assessment. Is this the norm now? Do med/surg RNs chart their "make believe" assessment every day?? How do they do this and just flat out lie every day without being caught ? She spoke up at first, but soon tired of feeling like some crazed out NP who was being so picky about her care. She thought it would be interesting to see who would and who would not do an assessment. She says the new RN will come on shift, say hello, walk up to the in room computer and start charting a bunch of notes, pass meds and then continue with the same pattern all day. No bowel sounds auscultated, no lung sounds auscultated. Magical patient care without touching the patient !! This is at a pretty major size hospital too in a major metro area. I have to say I experienced something similar a few years ago but not nearly as bad.
icuRNMaggie...my comments were not at one person in the profession. My comments were at what I am seeing as a general trend. Individuals (NP, MD, RT, RN, etc. etc. ) are ALWAYS going to let you down, but when the trend in general is shabbing out of what you know is right and what you know you are supposed to do, then I'm going to call it out.
I have no doubt missed things, misdiagnosed things too. I'm not perfect. There is not an RN who is perfect and knows everything and there is no NP who is perfect either. But I have never and will NEVER ever chart something I didn't do, nor will I shirk the duty I take for the day. If you are going to be an RN, then by golly be an RN and pop that stethoscope on the back and over the tummy at LEAST.
Sadly, I think some of the RNs who don't/won't/can't do an assessment at the bedside, somehow make it onwards thru NP school....sounds like you have encountered some of those. I've been to some of those NPs and PAs. They shab out on the PH, ROS and their assessment is minimal. Very sad. I don't know how they make it through.
I am highly offended by your original post directed at ALL hospital RNs and MDs as well as
your immature, dismissive and unprofessionally worded response.
First of all, I think it is quite telling that a person with an advanced degree would use vulgar street slang to describe the alleged actions of one's colleagues. Google it. What a disgusting expression.
Second, your comments most certainly were directed at two groups of the medical profession, hospital RNs and MDs. If not, CHANGE the TITLE of your thread. If you really are seeing this in your NP practice why are you "Calling it out" here, the general nursing forum ?
Third, the malpractice, gross negligence and complete and utter stupidity described in my first post aren't just "missing things." Tell that to my friend who can not conceive, the patient whose metastatic ca went undiagnosed for two years, the hepatorenal failure patient who has ESRD (that means chronic dialysis for life) and the family of the patient who died of aspiration pneumonia. Though they all did have the misfortune of encountering incompetence and it does support your assertion on NPs who "shab out" by doing minimal assessments. How do they get through you ask. We all know that there are NP programs that have no experience, no references, no interviews, no GRE and only a 2.5 GPA , a checkbook and fewer clinical hours than an LPN required.
Fourth, I certainly hope that you do more than "by golly pop that stethoscope on the back and the belly!"
I assure you that auscultation of heart and lung sounds are done without exception in the inpatient units in every hospital where I have worked. Bowel sounds and the absence there of, have not been considered a valid assessment of an SBO or anything else, for almost twenty years. Look it up.
Faking assessments is not a "trend" in my region. If it is a "trend in general" in your area, the appropriate professional response to your friend's perceived inadequate care would have been a thoughtfully worded letter to the VP of Patient Care, not this inflammatory and contentious post on an anonymous internet forum that incited 12 pages of nurses bashing nurses. Comments like yours make us all look dumb and contribute not so much towards the advancement of nursing than towards it's demise.
I just finished my 1st semester of nursing school and during clinicals I never saw anRN do any kind of assessment. I seriously could not believe it. And I was there during shift changes every single time.
Are you sure about that? If so, think again. Most of an assessment is not obvious and does not require a stethoscope.
I am assessing my patients starting from the moment I first walk into their room and lay eyes on them. Some things are obvious with visual observation like pallor, respiratory effort, IV site/location, ect. As I introduce myself I am also assessing most of their neuro status and LOC. If I take the patient to the bathroom then I am assessing mobility, skin, GU/GI, ect, the patient isn't even aware that I am looking at these things.
Many important questions can be asked in a casual way without seeming formal. How are you feeling today? Tell me about your pain. Have you been coughing or short of breath? Is your appetite well, have you been nauseated? When was your last BM and was it normal for you? Have you had difficulty urinating?
Physically I will assess lung fields, heart sounds, bowel sounds, pedal pulses, ect. But this all takes me less than five minutes.
So when you say you didn't see an RN do ANY kind of assessment, I don't believe that to be true, since most of an assessment is done without being obvious.
Yes this is common. Not only to med-surg but also the ICU. From both nursing and medicine. It is shocking and scary. I can do a full head to toe assessment in 5 minutes, I do not care how busy you are there is no excuse for not assessing.
We can copy assessments from a previous shift and then just make changes and I sometimes wonder if we are talking about the same patient. The physicians notes are just as bad. How can a doctor who spent 5 minutes questioning the nurse chart a full head to toe assessment and plan and then note "45 minutes of critical care time spent with this patient" with a clear conscience?
Yes, they do it with a clear conscience. Physicians have home access to PACS and the EMR and review PCXRs, AML and ABGs and charting before coming to the hospital. It is not uncommon to have them call me for an update at 6am. They have to deal with consents, families, vent changes, reading CTs in Radioogy and calling consults and coordinating the plan of care along with progress notes and order entry. Just because they are not in the patient's room or physically in the ICU for 45 minutes does not mean that they have not fully examined the critically ill patient and invested a significant amount of time on his or her medical care. They deserve to be paid.
After rounding they have office hours and on call. 45 minutes a day is an under estimation of the time spent on one ICU patient.
I am highly offended by your original post directed at ALL hospital RNs and MDs as well as
your immature, dismissive and unprofessionally worded response.
First of all, I think it is quite telling that a person with an advanced degree would use vulgar street slang to describe the alleged actions of one's colleagues. Google it. What a disgusting expression.
Second, your comments most certainly were directed at two groups of the medical profession, hospital RNs and MDs. If not, CHANGE the TITLE of your thread. If you really are seeing this in your NP practice why are you "Calling it out" here, the general nursing forum ?
Third, the malpractice, gross negligence and complete and utter stupidity described in my first post aren't just "missing things." Tell that to my friend who can not conceive, the patient whose metastatic ca went undiagnosed for two years, the hepatorenal failure patient who has ESRD (that means chronic dialysis for life) and the family of the patient who died of aspiration pneumonia. Though they all did have the misfortune of encountering incompetence and it does support your assertion on NPs who "shab out" by doing minimal assessments. How do they get through you ask. We all know that there are NP programs that have no experience, no references, no interviews, no GRE and only a 2.5 GPA , a checkbook and fewer clinical hours than an LPN required.
Fourth, I certainly hope that you do more than "by golly pop that stethoscope on the back and the belly!"
I assure you that auscultation of heart and lung sounds are done without exception in the inpatient units in every hospital where I have worked. Bowel sounds and the absence there of, have not been considered a valid assessment of an SBO or anything else, for almost twenty years. Look it up.
Faking assessments is not a "trend" in my region. If it is a "trend in general" in your area, the appropriate professional response to your friend's perceived inadequate care would have been a thoughtfully worded letter to the VP of Patient Care, not this inflammatory and contentious post on an anonymous internet forum that incited 12 pages of nurses bashing nurses. Comments like yours make us all look dumb and contribute not so much towards the advancement of nursing than towards it's demise.
I agree that the OP did generalize his/her post to hospital nurses and MD's. I agree with your comments about NP training; in my research of NP programs (at reputable universities) I have seen clinical hours from the mid 450's to 600. NP education and training is far removed from physician education and training. I agree with your comments about listening to the "lungs and belly" - obviously a thorough assessment involves much more than just "popping on a stethoscope."
I agree that writing respectfully and avoiding the use of slang would have been preferable.
I wanted to mention that a recent Medscape article on large bowel obstruction clinical presentation dated April 22, 2014, does refer to bowel sounds being diminished. As far as I can determine, auscultating bowel sounds as part of a nursing assessment is still of value.
Where I did find agreement with the OP was on his/her feelings about the lack of assessment that his/her friend (with sepsis) experienced. I do feel that those comments are valid. I have observed the same, on occasions, as I mentioned, when my family members have been hospitalized, and other nurses on this thread have attested to their own experiences and those of their family members in this regard.
I agree that the OP's post was somewhat inflammatory. From my own experience I know that one's emotions are considerably heightened when one's family member/friend receives less than adequate care, so I don't find it too hard to overlook that aspect of his/her post.
Bowel sounds and the absence there of, have not been considered a valid assessment of an SBO or anything else, for almost twenty years. Look it up.
From my reading, bowel sounds - their presence or absence thereof by themselves, are not considered diagnostic of bowel obstruction, but both small bowel and large bowel obstructions show altered patterns of bowel sounds, and the recommendation for diagnosis in symptomatic patients is that the physical exam (which includes auscultation of bowel sounds) is performed in conjunction with the radiologic exam.
So auscultating bowel sounds is still of clinical value to the patient during day-to-day nursing assessments, as altered bowel sounds can be indicative of bowel obstruction.
No, it is not old school practice. How can you chart when you haven't assessed the patient? No excuse; however, your NP friend could have easily asked how her lungs were sounding or how her skin was looking. I am sure the nurses would have caught on and performed a complete head-to-toe. Pt is just as responsible.
Yes, they do it with a clear conscience. Physicians have home access to PACS and the EMR and review PCXRs, AML and ABGs and charting before coming to the hospital. It is not uncommon to have them call me for an update at 6am. They have to deal with consents, families, vent changes, reading CTs in Radioogy and calling consults and coordinating the plan of care along with progress notes and order entry. Just because they are not in the patient's room or physically in the ICU for 45 minutes does not mean that they have not fully examined the critically ill patient and invested a significant amount of time on his or her medical care. They deserve to be paid.
After rounding they have office hours and on call. 45 minutes a day is an under estimation of the time spent on one ICU patient.
Charting a physical assessment means physical assessment, not reviewed patient's chart. I work in ICU so I am familiar with how much time a doc may spend on an ICU patient. I fully understand that docs have huge demands on their time. I also understand that they have access to xrays/lab/vitals/fluid status etc prior to ever showing up. I understand they may have spent more time than I personally have seen with my own eyes and do quite a bit of work behind the scenes.
We have some great docs on my unit and it is obvious they are paying attention. We also have some crappy ones who do not pay attention, rely on the nurses and residents to point things out to them, and this is also obvious. It is obvious when their charting does not match (could not) match the patient's /condition/test results/etc. It is obvious when they are entering d/c orders on patients who are either stopped from transferring by an attentive RN/resident or turned right back around and re-admitted by the receiving floor because they are clearly in trouble.
Literally the assessments, notes, and plans they are charting totally contradicts the patient's test results, physical condition, ER presentation and computer captured vitals. If they would have at least laid eyes on the patient they would have noticed something wrong. Like the patient is breathing 40 bpm's, is on a NRB, is gray, and is absolutely not WNL respitorially and ready to be transferred out.
Doctors are not the only ones guilty of this, RN's, resident's, RT's, etc are as well. When you have a group of them all working on the same patient for multiple shifts patients can and do get in trouble. When you can literally go through the chart and track an expanding bleed via CT for days on the patient who crumped "suddenly" despite being A&Ox4, GCS 15, PERRLA bilaterally, MAE for those same amount of days?
When these incidents happen repeatedly, to the same people, over and over again?
And it may not even be an issue of malicious intent. In some cases it may be inexperience/not realizing what they are seeing, difficult dx's etc. Like the tricky foot fx that isn't totally visible on xray. If you never go in and look at the foot, see the swelling, bruising, etc. for yourself.
Physical assessment is important in my opinion. Even with x-ray, labs, CT, reliable notes etc. I know that my RN and MD coworkers as well as myself have caught things just by physical assessment alone. DVT's, dehissed wounds, fractures, etc. Even if all you glean from your physical assessment is that the patient just doesn't look right at least you know to keep a closer eye on them.
new RN's -getting out on time, charting all done, texting in the charting room, while me-older and "old school" gets out late, frustrated seeing their pts lying in same position most of shift while the nurse get their charting done. I'm sure they are not assessing the pts. Feeling a pedal pulse? I don't think so-not when I had to dopple it when I had the pt. Sick of it and burnt out....stuck.
That said, as a "hospital RN" with extensive experience in critical care, I can say with absolute certainty that overall, mid-level providers (NP's and PA's) do the worst assessments, have a highest ratio of wrong diagnoses, and contribute more to poor patient outcome than RN's and MD's.
I can say with absolute certainty that overall, mid-level providers (NP's and PA's) do the worst assessments, have a highest ratio of wrong diagnoses, and contribute more to poor patient outcome than RN's and MD's.
icuRNmaggie, BSN, RN
1,970 Posts
I am highly offended by your original post directed at ALL hospital RNs and MDs as well as
your immature, dismissive and unprofessionally worded response.
First of all, I think it is quite telling that a person with an advanced degree would use vulgar street slang to describe the alleged actions of one's colleagues. Google it. What a disgusting expression.
Second, your comments most certainly were directed at two groups of the medical profession, hospital RNs and MDs. If not, CHANGE the TITLE of your thread. If you really are seeing this in your NP practice why are you "Calling it out" here, the general nursing forum ?
Third, the malpractice, gross negligence and complete and utter stupidity described in my first post aren't just "missing things." Tell that to my friend who can not conceive, the patient whose metastatic ca went undiagnosed for two years, the hepatorenal failure patient who has ESRD (that means chronic dialysis for life) and the family of the patient who died of aspiration pneumonia. Though they all did have the misfortune of encountering incompetence and it does support your assertion on NPs who "shab out" by doing minimal assessments. How do they get through you ask. We all know that there are NP programs that have no experience, no references, no interviews, no GRE and only a 2.5 GPA , a checkbook and fewer clinical hours than an LPN required.
Fourth, I certainly hope that you do more than "by golly pop that stethoscope on the back and the belly!"
I assure you that auscultation of heart and lung sounds are done without exception in the inpatient units in every hospital where I have worked. Bowel sounds and the absence there of, have not been considered a valid assessment of an SBO or anything else, for almost twenty years. Look it up.
Faking assessments is not a "trend" in my region. If it is a "trend in general" in your area, the appropriate professional response to your friend's perceived inadequate care would have been a thoughtfully worded letter to the VP of Patient Care, not this inflammatory and contentious post on an anonymous internet forum that incited 12 pages of nurses bashing nurses. Comments like yours make us all look dumb and contribute not so much towards the advancement of nursing than towards it's demise.