So disappointed in hospital RNs and MDs

[carachel2]

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?

[been there,done it]

In my 30 years of floor nursing experience... I have seen this over and over again.

After all.. if it's charted.. it's done. The physician and the nurse are now covered.Even IF IT WAS NOT DONE.

My father DIED because bowel sounds were charted, but the lack there of was not .. He died from bowel obstruction. Some little chickie-poo ( and the doctor) checked the box for bowel sounds present in all 4 quadrants.

We are professionals, responsible for an assessment on every system.. every shift.. even if it's a quickie!

I got out of a LOONG report one morning.. the first patient I assessed had already been seen by her physician. Doc had already seen the patient.. and charted normal lung sounds.

I still took 5 seconds to auscultate.. NO lung sounds on the right side... got a chest xray.. spent the morning plunking in a chest tube.

Bottom line.. use your assessment skills... that's what our patients need.

[VANurse2010]

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.

I wouldn't think so. One of the criteria for psych admission is medical stability, which in my view means periodic (daily) vital signs should be sufficient. Now, I have seen psych nurses chart a physical assessment without actually doing one - that's not OK - but that was on admission. They need an admission assessment, but I don't think a qshift physical assessment is necessary. If one is, then they should be in a medical unit and not on psych.

[annie.rn]

I don't even know where to start. I am in total agreement w/ the OP. I started a thread about an MD not doing an admission assessment and then charting it:

https://allnurses.com/showthread.php?t=961771

I find it appalling that a nurse would chart an assessment they didn't do. What about integrity??

I work on a busy med/surg unit and I can honestly say I have never charted an assessment I didn't do. If I miss something I go back and assess it or I leave it blank. All of my patients get a head to toe assessment each shift, focusing the most attention on assessing the system that is related to the admitting diagnosis. I even carry a pen light and assess pupils.

Some of the things I have discovered when I roll a patient over to check their skin/listen to posterior breath sounds makes it obvious that people are charting things they haven't assessed.

Now that I am reading in the replies that this is very common, it makes sense to me why I am always busting my butt and running around non-stop my whole shift while others are done passing meds and are sitting at the desk texting by 2200. I manage to get it all done and get out on time for the most part but I go go go the whole shift.

I have had patients tell me several times that I am the only one that has assessed him/her.

One of the best physical exams I have personally had was a NP in a GI practice. She could have gotten by w/ a quick abdominal exam but she did a very thorough head to toe.

I understand that the demands on healthcare providers are ridiculous these days but there are some things you just don't skimp on.

If the nurses aren't doing assessments and then basing their plan of care off of what they find then what are we there for? We are obligated to "do no harm". Harm can be done by not doing an assessment and thereby missing a crucial change in status indicative of a complication.

I have noticed a major decline in the quality of patient care and a huge incline in the number of patient complications in the past 5-10 years. (Been a nurse for 22) Complications that have resulted in deaths. (Off the top of my head there have been two deaths on the floor I work on in the past year alone.) A person should not come in for an elective joint replacement and leave in a body bag secondary to complications from a bowel obstruction.

Maybe I'm too old school.

[aleii]

Yet another reason why we need mandated nurse-patient ratios!

[nurseprnRN, BSN, RN]

The last time I was in the hospital, I had to ask the admitting nurse if she wanted to reconcile my meds and despite being in the ICU/on the monitor, never had anyone respond when every time I stood up my heart rate skyrocketed to the 150s d/t orthostasis. No one bothered to check a standing BP on me either.

That happened to me the last time I had to have ER care-- I had been having awful GI symptoms that just were not resolving and I could tell I was grossly hypovolemic. Somebody took my BP when I was lying down on the gurney, but they said it was fine, 110/70. I had to tell them to take it sitting and then standing. We got as far as sitting (82/50) and left off there, since standing wasn't really a safe option at that point. Next thing I knew I was getting three liters of RL.

I really resent being sick as hell and having to tell people to effing listen to me when I tell them. I always feel bad for the people who don't know the lingo. Another great example: Do you want to know how to get stat attention at two o'clock on a Friday afternoon of a holiday weekend? Don't tell them just, "My vision is a little sorta fuzzy." Say, "I have developed a central visual field defect over the last 36 hours," and watch 'em hop to.

[tokmom, BSN, RN]

Heck, After having my last child, I was listening to the report by the off going nurse. My episiotomy looked good (didn't have one), my fundus was hard and WNL and my lochia was minimal and I was breastfeeding well. The truth?? Fundus was occasionally boggy, the lochia heavy at times, breastfeeding was causing huge after pains and the barracuda child that I was nursing was killing my nipples. I had also spent the few first hours after birth nauseated because the methergine they gave me caused intense nausea, and I was still suffering.

OP as a med/surg nurse I have some suspicion of a few nurses that do just that, especially when the pt said they were never awakened the entire night. Anyway, I do not see it on days but our nurse/pt ratio is adequate.

[ontheway2crna]

I think there's a certain element of "why bother?" (not saying that's OK) when so little of medical decisions are made based on physical assessment, and in most hospital environments the nursing assessments are not read or taken seriously.

I disagree with this, because If I hear lung sounds that are diminished or there are now fine crackles in the bases, or the heart rhythym is irregular, I call the doctor and I tell them. There have been time swhere my head to toe assessments have made a difference in my pt's care. Often, I have been told there are dressings on people's backs when there were not, and I find things that people "miss" or may not have even bothered to assess, so I cover my butt and I assess.

[Yuppers21]

I think the lesson to take away from this is that while nurses (and other health professionals) are expected to accomplish more than can be reasonably done in a single shift, there are some things that cannot be skipped. Sometimes there isn't enough time to give a full bath for a pt on bed rest, missing one q2hr turn probably won't result in a new pressure ulcer and giving a stool softner 45 min late one time won't likely set the patient's healing process back by a whole lot. However, every patient needs a full assessment every shift and focal assessments beyond that. Sometimes limitations require us to cut corners. Make sure they are ones that have the smaller chance for an adverse outcome to the patient. Don't mentally excuse yourself for not fully assessing your patients because you completed some other less important task instead.

Also, let's be understanding of one another's struggles. I'm sure that the many nurses who have done this did so believing that the patient was stable and would not be harmed by "one" missed assessment. It may not have been the correct decision, but certainly doesn't equate to intentional harm. It's important to remind ourselves and our coworkers where our priorities should lie but let's not set out on witch hunts and feel it our duty to ruin their careers. There are plenty of other systems in place to do that.

[been there,done it]

Spot on Grn Tea.

In my current position, I screen criteria for payment for hospital admission.

When Syncope is the dx... if no orthostatic reading is done .. the admission is DENIED.

The patient is not receiving intensity of service.

It's should be a no brainer to check orthostatic vital signs.. amazing how the basics are missed.

[MunoRN, RN]

As you've correctly pointed out, nursing practice is being slowly phased out. I completely agree it's unacceptable for nurses not to be performing basic nursing assessments (which by the way wouldn't have caught the pleural effusion, which can only be differentiated through percussion which isn't part of the general scope of nurses), but if you've noticed the same problem then it's the overall trend of taking away nurse's ability to be nurses that should be what you want to change.

[SubSippi]

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.

At my hospital the psych unit won't have anything to do with a patient with ANY sort of medical issue. They give them regular, daily meds prescribed by their PCP but that's it. I once had a patient who was violent, threatening to kill all of us on the floor. He was restrained but kept breaking OUT of his restraints, because he was young and in really good shape and we could only use soft restraints anywhere outside of the psych unit.

Psych wouldn't accept him, because he had a rash on his shin that was diagnosed as cellulitis, that he was supposed to be receiving antibiotics for.

I didn't do an assessment on him...don't remember what I documented.

[erifica]

I work on med surg. I do a full head to toe twice a day and focused assessments if something seems different. I usually have four patients; sometimes five. I'm new to the profession. I even do it on "psych" patients. If they're there for a medical reason, they need to have a complete head to toe. Period.