So do you really...

[LouisVRN]

do a complete head to toe assessment? What are things you ALWAYS assess? I've been told by patients that I'm the first to listen to them with a stethoscope. How do you document when you did not do a complete assessment on an area (ex. deferring a reproductive exam on an appy pt)?

I have a list of always assess things - cardiac/lung/bowel sounds, radial/pedal/post tibial pulses, sensation, basic neuro status, access device, pain. Then focus on whatever the problem is and assess that.

just curious on everyone's practices.

[regularRN]

I always listen to lung and heart sounds, check for edema... listen to bowel sounds; and then, depending on the pt.'s diagnosis, I will perform a more focused assessment - e.g., neuro.

I always perform a head-to-toe skin assessment, albeit during opportune moments such as transfers, ambulating, repositioning and bed baths.

[Five&Two Will Do]

I am work in an MICU so I usually only have 2 patients. This makes it much easier to do a thorough assessment. I definately listen to lungs, heart, bowels. I talk about breathsounds, quality of breathing Vent settings or whatever supplemental O2 they have etc. With the cardiac I talk about sounds of the heart, rhythm on monitor, capillary refill, pulses etc. With the GI its the BS, I mention diet and any feeding device NG, OG , dobhoff. I do general neuro assessment ie pupils, orientation, behavior and speech. GU system includes any urinary device, amount and quality of output, edema. skin assessment, musculoskeletal includes weakness mobility, etc. I talk about venous access, infusions, code status, allergies, and any lab values that ore abnormal. If I have the same patients 2 or three days in a row, it becomes much quicker and easier to do these assessments. I hope of course that there will be less and less abnormal findings. It seems like a lot, but the more I do it the more efficient I become and so will you!

[Anna Flaxis, BSN, RN]

When I worked in an inpatient unit, I did full head to toes. In the ED, I do focused assessments. If the patient is admitted, then I do a head to toe.

[Chaya, ASN, RN]

The paperwork we have to fill out kind of sets the basic framework for me. We have to fill out a flowsheet Q shift that includes a general head-to-toe assessment, skin and vital signs. You at least have to check off that you have assessed each system plus add a short description of any deviation from the norm. Plus I specify my observations in whatever area the pt has issues (ie- dx of COPD I record my observations of lung sounds, resp rate and effort etc whether abnormal or not and state if baseline for this pt this admission.

[steelydanfan]

It's hard to answer this as an experienced nurse, because we sometimes sort of "blend" a bit. I do a complete head to toe, but it won't be the same as a new grads head-to-toe, because I see things more readily than they do.

I don't palpate a bladder on a pt. without URO probs because I can

assess the bladder during my GI exam readily, and ask the pt. a few questions about voiding.

I do my MS exam with my neuro exam, except for the active ambulation portion.

I can assess muscle strength and neuro deficits at the same time.

So, yes, we do the same things, we just do them a bit differently.

[Humerus Nurse]

I always do a full head-to-toe assessment but once you do so many, you can get it done pretty quickly. If the pt is younger and able to get up and walk around all by themselves, then I may not perform an overly detailed skin assessment for developing pressure ulcers .

[FunRun]

It depends where you work and what the policy states. I work in a Cardiac ICU and we do complete head to toe assessments every 2hours and prn as well as VS every 2hours and prn. As far as a reproductive exam, I am not really sure what you mean? All this information should be clearly stated in the standards of care for your unit/facility in which you work. Hope this helps!