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.
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.
A little off topic but at the hospital where I work the nursing assessments are not even visible to the providers. Its a shame.
I work nights. I can tell you that myself and all of my co-workers carry stethescopes, and do a general assessment (lungs, heart, BS, pedal pulses and edema) Qshift. I also check IV sites (IVF infusing check for infiltrates and if locked then flush), and surgical wounds, colostomies and foleys etc...I also know my co-workers do because I've been in the room when they've been done. By contrast in general only one or 2 of the dayshift nurses carry steths, and I've seen them charting full assessments by 8:05 after getting out of report at 7:30. Not sure how that works exactly...
Yeah, I work on a cardiac telemetry floor and I get patients or family members all the time asking why I'm checking their pedal pulses/radial pulses post angio or state that I'm the first nurse that has done a full assessment on them-- often. It bugs me when I feel that many of the other nurses I work with are barely doing a minor assessment, the ones who seem to be able to sit half their shift sitting in the nursing stations charting rounds they aren't doing,eating, or drinking coffee-- when we have patients with multiple comorbidities. I can't prove it of course, but it seems like some of them just copy verbatim what the other nurse charted on the previous shift for their assessment. I can count a handful of nurses out of the 50 I work with that I would trust even taking care of one of my family members. We are a really busy floor with "heavy" patients a lot on our floor, but that kind of laziness is inexcusable and management does hear things about the nurses that barely do their job, but apparently they are "good enough" for our floor. Of course they always get out of work exactly on time, while I usually don't. It frustrates me that I go out of my way to take good care of the patients and I have to follow a nurse that never has the wound care done, equipment ordered, go-lytely finished for pt, etc, etc, etc and then I'm expected to get it done. I completely understand being busy, but hate when it is just from being chronically lazy and it's always the same nurses or nurse aides.
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.
I just want to mention that although this can be uncomfortable to do, as nurses it is our duty to continue to advocate for our patients if a physician is not responding appropriately to our informing him/her of patient conditions that need to be addressed, in order to obtain necessary medical care for the patient. This can be accomplished by going up the chain of command, from Nursing Supervisor to Medical Director, if necessary, all the while documenting our efforts and their outcomes, until the patient receives the necessary medical care.
Specializes in LTC, assisted living, med-surg, psych.
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.
That explains it, then. But I must say that when I was IP, there was a young woman who was diagnosed with type II DM on the unit. They didn't let her go home until her BG levels were WNL and she'd gotten some diabetic teaching, even though her psychiatric condition had stabilized. She had a few incidences of feeling light-headed, and naturally I advised her to lie down (can't help being a nurse even when I'm a patient!) while I got the nurse to assess her and do a FSBS. To be honest, it wasn't a head-to-toe, but at least she got a focused assessment. I didn't realize that they aren't normally done on a psych ward. Shows you what I know. LOL
In the in patient psych unit where I work, we do assessments that are focused on mental status, but there is fall risk, ROM, body injury, and a few other things added in. I check my patients vitals and graph, as well as labs every time I am on shift, I have picked up things going south that way.....because it's my JOB.
We do sometimes get patients with medical conditions, like I had a gal with a G tube, and you can bet I checked placement, return, and changed her tubing etc....which by the way, when I picked her up it had been left there for three days with crusted jevity around the caps along with crusted stuff everywhere else as well. So I get that we are overworked and under appreciated, but WTH? That is just wrong that we as nurses are so lax in care.
I actually became a nurse because medical professionals almost killed my kids on three different occasions years ago when they were small. I swore I would never be ignorant again in regards to care. That being said there are nurses and Dr.'s out there that I think walk on water, just sayin.
This is a "systems"problem. Yes the RN should do a full assessment but we must look at the reasons why this workaround happens so frequently. Only then we could begin to address the root cause for this behavior.
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.
No one is saying that psych patients shouldn't be assessed if they are on a medical or surgical floor. The question was about psych patients in a psych unit - and no, those folks don't need a head-to-toe physical assessment qshift.
I feel bad when I can't do a thorough assessment, but I make it my mission to check LOC, pain, hand grip, orientation, heart, lungs, bowel sounds, edema, pulses and bottom if incontinent/immobile. I try to get posterior lung sounds but sometimes it is difficult to turn a large patient by yourself.
I was handling four patients as a student. Not sure if I will be able to even do all that as a nurse with five or six patients.
It takes 5 minutes to do a complete head to toe. How can you give a heart or BP med without first assessing the systems they're prescribed for? There is at least 5 minutes in a shift to at least do a focused assessment and inquire of other issues; especially if the pt is A&Ox4.
Specializes in NICU, PICU, Transport, L&D, Hospice.
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.
Your fake charting allows your employer to pretend that they are providing adequate staffing. Grow a pair and act like a professional, it's YOUR license and reputation on the line.
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.
As a new grad one month into my hospital orientation, this was very helpful, thanks! I'll always make sure I assess every patient.
Loo17
328 Posts
A little off topic but at the hospital where I work the nursing assessments are not even visible to the providers. Its a shame.