So disappointed in hospital RNs and MDs

Nurses Relations

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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.

Thoughts?

Specializes in Acute Care - Adult, Med Surg, Neuro.

I'm a medical-surgical RN and I do a COMPLETE assessment on each patient at the beginning of my shift and with any changes. There is no excuses. I do basic mentation (AAOx3, forgetful? eyesight hearing), respiratory system (lungs, cough, ask about sputum production, and do they feel short of breath), heart (listen to heart tones and ask about chest pain), belly (bowel sounds, ask about nausea, are they passing gas, nauseated, and when was the last time they moved their bowels). I then palpate radial and pedal pulses and assess for edema. Finally, I check for wounds and at IV / drain / tube feeding sites. If the patient is bedbound I bring my nursing assistant in with me and turn to assess the buttocks and to see if the patient is incontinent. I ambulate most of my patients x1-2 a shift to assess movement. I also cross check IV infusions and drips at the beginning of the shift.

I will also do focused assessments (neuros if ordered, angio sites, surgical dressings, CIWA / withdrawal scale) more frequently if ordered (q2-4hr). I also assess patency of central lines once a shift with flushes.

I am insulted that many people assume medical surgical nurses are lazy with their assessments. Most of my assessment I can get with just laying eyes on and discussing with the patient.

Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
I'm a medical-surgical RN and I do a COMPLETE assessment on each patient at the beginning of my shift and with any changes. There is no excuses. I do basic mentation (AAOx3, forgetful? eyesight hearing), respiratory system (lungs, cough, ask about sputum production, and do they feel short of breath), heart (listen to heart tones and ask about chest pain), belly (bowel sounds, ask about nausea, are they passing gas, nauseated, and when was the last time they moved their bowels). I then palpate radial and pedal pulses and assess for edema. Finally, I check for wounds and at IV / drain / tube feeding sites. If the patient is bedbound I bring my nursing assistant in with me and turn to assess the buttocks and to see if the patient is incontinent. I ambulate most of my patients x1-2 a shift to assess movement. I also cross check IV infusions and drips at the beginning of the shift.

I will also do focused assessments (neuros if ordered, angio sites, surgical dressings, CIWA / withdrawal scale) more frequently if ordered (q2-4hr). I also assess patency of central lines once a shift with flushes.

I am insulted that many people assume medical surgical nurses are lazy with their assessments. Most of my assessment I can get with just laying eyes on and discussing with the patient.

I am so glad there are still good nurses out there. I don't think the aim was at med surg nurses...it was aimed sat the medical profession as a whole.

I am a professional patient. I have an auto-immume disorder and I see many physicians, residents, NP's, nurses, and MA's that call themselves nurses. I can say with authority that the lack of physical assessment is appalling. This involves different prominent medical facilities (due to the rarity of my disease) IF I get my B/P taken with an O2 sat I consider myself fortunate.

A recent trip to the ED lead to emergency surgery and a stay in ICU....with subsequent complications that lead to a couple more admissions I can again tell you with authority that the lack of physical assessment boggles the mind. Maybe they felt that as a nurse I would tell them if I felt there was something was awry with my assessment, however, as the patient I shouldn't have to do my own assessment.

I know that staff left my room rolling their eyes for I would ask as they were leaving...."Since I had bowel surgery would you like to auscultate my bowel sounds?" But it made me angry. I know darn well they went straight out to that computer and filled in all those checkmarks to be sure there was no space left unchecked. Many believe if they document it of course it was done....well...that isn't the case so much anymore.

I get that nurses are busy...but I remember the days of team nursing where there was 2RN's 2LPN's and 2 aides for 35 surgical patients....9 a piece....all with foley's, NGT's, drains (JP's, T-Tubes, multiple penrose drains) I know that there were nurses that skimmed assessment however I know that we didn't miss many. I know I didn't miss a single assessment. Sure it was done at noon when I got to their bath but it was still done.

All this "I'm a BSN RN", "that's not my job", "Whatever...I'm just putting in time. I'm in school for NP" that I have seen and heard as a supervisor when I make rounds (and I have seen it here) frustrates me and makes me angry. It makes me angry that so many of the newer programs don't even teach assessment...."that is for an advanced degree". What a load of feces.

We as a profession need to get a grip. Where are we going? Where will this all end up? Who is going to be caring for you when you need it?.....we all get old.

ONce again I just sit here shaking my head.

Until someone sues. Then every word is taken very seriously. I'm scared to death to chart an assessment I didn't actually perform. You can't know which one is going to come back to haunt you. Are there really that many nurses not bothering to do assessments? Scary. Don't get sick.

Yeah. Until they are sitting at that long lawyers table giving a deposition with two bright lights shining on you and every.single.note typed and printed in front of you and a hot shot med-mal attorney who can talk circles above an MD and whose knowledge of medical terminology and pathophysiology is superior to ANY patho profressor you ever had...and then you are going to WISH they hadn't taken a shortcut.

I think the hands-on full physical assessment is not just a nursing issue. Doctors have become a lot less fluent with the details of the physical assessment in favor of diagnostics. I rarely see doctors listening for breath sounds, percussing or palpating anything. If they are concerned, a chest Xray gets ordered. Lab results, scans and diagnostic testing are what direct the medical plan.

Talk to much older doctors and this wasn't always the case. A family friend remembers having to do complete and very thorough physical assessments and present the patient on rounds to the attendings. There was little diagnostic technology and a good patient interview and assessment was part of the detective work of medical diagnosis.

I wonder if some of this attitude rubs of on nurses?

Specializes in Oncology.

I don't work med surg. I work in a more critical care area and typically have 3 patients per shift. They all get a fairly thorough assessment each shift.

Last two times I was in the hospital I was on a telemetry unit and all of my nurses at least listened to my heart and lungs.

Specializes in General Surgery, NICU.

I work on a surgical floor and the rounding attendings/residents will rarely place a hand on their patients or even listen to lung/bowel sounds; its appalling! Recently I had a patient who was wheezing and SOB (having a COPD exacerbation) and when the attending rounded on him the patient was sleeping. I spoke with the attending that his breathing was getting worse and the MD poked his head through the curtain and said "his breathing is fine" and was out the door.

As for nurses, I know some who do NOT do assessments and BS their way through report. It is very disheartening and a huge disservice to our profession and our patients.

Specializes in ICU, ED.

I was a CNA/PCT in nursing school and I would frequently have to sit in 1:1's with patients who had "AMS" (and by AMS I mean "that one dose of dilaudid made them loopy" and now they need a sitter….:sarcastic:). We usually had a computer in the room to chart VS and hourly 1:1 rounds, and I would read the notes and assessment flowsheets when I was bored. The nurse would come in the room once or twice at the beginning of the shift to introduce herself, give some meds, and then a couple hours later an entire head to toe assessment would be documented without ever laying a hand on the patient. Now, I never got my acceptance letter to the nursing school of witchcraft and wizardry, so I can't fully attest to what they teach there, but I'm 99.9% sure that touching the patient is required in order to listen to their lung sounds or determine their pulses are a 3+. If there are some magical assessment techniques that allow you to gather assessment data from 3 ft away, I am not aware of them but I would love to learn.

But seriously, assessment is what separates RNs from LVNs and CNAs, etc., and if you aren't willing to do at least one head to toe assessment during your shift (preferably at the beginning) then why did you even become an RN in the first place? You can do a quick but thorough head to toe assessment in less than 5 minutes - if you don't know how then you should probably practice at home until you nail it down.

Specializes in ICU.

I have falsified charting before and I admit to it. My unit policy is q4h full assessments and q2h focused assessments. Sometimes an assessment, or a focused assessment, gets missed. I definitely make sure I check pulses and listen to heart/lung/bowel sounds at least three times per shift (more if related to why the patient is there) but I don't always check everything I am supposed to. Even in ICU with only two patients, if one is crashing and the other is so healthy that they have floor discharge orders but they are still mine because the floors are full, I can't say I make it in the healthier patient's room to assess something every two hours. Do I walk in the room, check on them, and ask what they need? Oh yeah, definitely - I have to do hourly I/Os so I try to make it in the room and look at/talk to the patient at least every hour. I would love to just chart something like "Talked with patient, brought her water, remains A&Ox4 and denies pain," but that doesn't cut it with what is required with my job's charting, and they audit our charting frequently. People get written up over not documenting mouth care q2h on my unit if the patient is NPO, as an example, even if the patient is awake and capable of doing his own mouth care.

Do I always do q2h mouth care? You know, I really try to, but sometimes I am just too busy. Is it worth getting written up for to document that I am not able to follow hospital policy and admit that I don't do mouth care q2h? If we get written up here, we are automatically denied a raise the next year. Is it worth losing money over one time not doing mouth care and being honest about it? Is it worth my job being honest multiple times? I think I am a good nurse. I think it would be great if my job encouraged honesty and didn't punish nurses for the small stuff. Maybe I am just selfish and a part of the problem, but if I only do mouth care four times a shift instead of five or six, I think I still deserve a raise that year, so yeah - there are times I falsify charting. I am not saying what I am doing is right. I feel guilty that I do what I do, but I still don't think it is worth the consequences of being honest. I am really starting to hate my job because of these many impossible, stupid requirements and having to choose between being honest and staying out of disciplinary action.

I have falsified charting before and I admit to it. My unit policy is q4h full assessments and q2h focused assessments. Sometimes an assessment, or a focused assessment, gets missed. I definitely make sure I check pulses and listen to heart/lung/bowel sounds at least three times per shift (more if related to why the patient is there) but I don't always check everything I am supposed to. Even in ICU with only two patients, if one is crashing and the other is so healthy that they have floor discharge orders but they are still mine because the floors are full, I can't say I make it in the healthier patient's room to assess something every two hours. Do I walk in the room, check on them, and ask what they need? Oh yeah, definitely - I have to do hourly I/Os so I try to make it in the room and look at/talk to the patient at least every hour. I would love to just chart something like "Talked with patient, brought her water, remains A&Ox4 and denies pain," but that doesn't cut it with what is required with my job's charting, and they audit our charting frequently. People get written up over not documenting mouth care q2h on my unit if the patient is NPO, as an example, even if the patient is awake and capable of doing his own mouth care.

Do I always do q2h mouth care? You know, I really try to, but sometimes I am just too busy. Is it worth getting written up for to document that I am not able to follow hospital policy and admit that I don't do mouth care q2h? If we get written up here, we are automatically denied a raise the next year. Is it worth losing money over one time not doing mouth care and being honest about it? Is it worth my job being honest multiple times? I think I am a good nurse. I think it would be great if my job encouraged honesty and didn't punish nurses for the small stuff. Maybe I am just selfish and a part of the problem, but if I only do mouth care four times a shift instead of five or six, I think I still deserve a raise that year, so yeah - there are times I falsify charting. I am not saying what I am doing is right. I feel guilty that I do what I do, but I still don't think it is worth the consequences of being honest. I am really starting to hate my job because of these many impossible, stupid requirements and having to choose between being honest and staying out of disciplinary action.

You mouth care should be q4H instead of q2H, and you do not need to document an assessment on even an ICU patient every 2 hours. Do these people want you to provide care or sit at a computer all day?

I have falsified charting before and I admit to it. My unit policy is q4h full assessments and q2h focused assessments. Sometimes an assessment, or a focused assessment, gets missed. I definitely make sure I check pulses and listen to heart/lung/bowel sounds at least three times per shift (more if related to why the patient is there) but I don't always check everything I am supposed to. Even in ICU with only two patients, if one is crashing and the other is so healthy that they have floor discharge orders but they are still mine because the floors are full, I can't say I make it in the healthier patient's room to assess something every two hours. Do I walk in the room, check on them, and ask what they need? Oh yeah, definitely - I have to do hourly I/Os so I try to make it in the room and look at/talk to the patient at least every hour. I would love to just chart something like "Talked with patient, brought her water, remains A&Ox4 and denies pain," but that doesn't cut it with what is required with my job's charting, and they audit our charting frequently. People get written up over not documenting mouth care q2h on my unit if the patient is NPO, as an example, even if the patient is awake and capable of doing his own mouth care.

Do I always do q2h mouth care? You know, I really try to, but sometimes I am just too busy. Is it worth getting written up for to document that I am not able to follow hospital policy and admit that I don't do mouth care q2h? If we get written up here, we are automatically denied a raise the next year. Is it worth losing money over one time not doing mouth care and being honest about it? Is it worth my job being honest multiple times? I think I am a good nurse. I think it would be great if my job encouraged honesty and didn't punish nurses for the small stuff. Maybe I am just selfish and a part of the problem, but if I only do mouth care four times a shift instead of five or six, I think I still deserve a raise that year, so yeah - there are times I falsify charting. I am not saying what I am doing is right. I feel guilty that I do what I do, but I still don't think it is worth the consequences of being honest. I am really starting to hate my job because of these many impossible, stupid requirements and having to choose between being honest and staying out of disciplinary action.

Thank you for being honest with us. Your post illustrates exactly what I was saying earlier.

Can I just say, restraint documentation? Every facility I have been in, I have had to chart on restraints q2h to the minute. Yeah, I've falsely documented. I don't drop everything and run into the room of a patient that has finally settled down to sleep and wake him/her up and do ROM and offer hygiene/hydration at 1400 on the dot. Nope, I look at 'em, make sure they're breathing and the restraints are on, as I'm walking by to put out a fire in another room, probably thirty minutes before or after I'm supposed to.

As I read all of these posts, I find myself getting really fired up over the thought of nurses not doing an assessment and documenting that they did it. Like I said before, I don't care how busy you are (med/surg nurses or otherwise), it needs to get done. Now, if you were coding one of your patients for 8 hours and you didn't get to see your other patients then I could see that being a viable excuse, but then you go and assess them before you leave so that at least it gets done and you can document it appropriately. Behavior like that violates the trust that patients place in healthcare providers. If I learned of a fellow nurse doing that type of thing where I work, I would spend every free waking hour working to make sure that they were not only fired, but also lost their license. Of course there are exceptions, but I think in general this type of behavior (as it sounds from previous posters) is somewhat pervasive and not secondary to the nurse being involved in an emergency for the entire shift. Here's the bottom line, it's OUR job to assess patients q shift and report any changes in the status of the patient to the provider. How are you possibly going to do that if you haven't assessed the patient? If it's a systems issue (shortstaffing, etc...) then obviously that needs to be addressed. But even so, I still don't see how a nurse can not do a thorough assessment q shift. Seriously, how long does it take a reasonably competent nurse to do a thorough assessment? Anyone who has graduated from nursing school SHOULD be able to do an assessment in less then 5 minutes. If a nurse has 6 patients, that means it would take him/her 30 minutes out of an 8 or 12 hour shift to do their job appropriately. Again, I don't care how busy someone is (outside of a code situation), you can find 5 minutes per patient to assess them. Period. Sorry, but this whole thing gets me really worked up.

Specializes in LTC, assisted living, med-surg, psych.

I wonder if assessments (or the lack thereof) are considered an issue in psych hospitals as well. People don't leave their medical problems at the door of the unit. As it happened, I was in decent physical shape except for my blood pressure and HR being too high, but not one nurse used a stethoscope on me the whole time I was inpatient.....just daily vital signs and weekly weights. However, one of the doctors conducted the most thorough physical exam I've had in YEARS. He checked DTRs, lungs, heart, bowels, edema, pulses, everything but a pelvic exam (which I'd had during the summer). Maybe that's the norm in mental health facilities, but I thought it was weird that no nursing assessments were performed.

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