Thorough assessments and keeping on schedule

[Moondance]

In our level II, the assignment is typically 4 patients per nurse. Two will be on an 8-11-2-5 assessment/feeding schedule and two on 9-12-3-6. Our time parameter for feedings is 20-30 minutes (though some will finish sooner).

There is a lot of variability of course with what types of patients we have in the assignment (ex: PO/NG feeds, ostomy care, IVs, etc), but I am curious what tips or shortcuts you may use to help keep to these patients on a workable/timely schedule. When I asked my preceptor, I have been told things such as to count the RR for only 6 seconds and multiply by 10, get the HR from the monitor, don’t feel for pulses (because if their limbs aren’t blue, they’re being perfused). But feeling for pulses is something we chart on the flowsheet that we are supposed to be checking each time.

When I ask questions (since it is so different what she is doing from what is taught in school), such as, “What about listening to all the lung fields to check for any adventitious sounds?”, or “Shouldn’t we listen longer in each quadrant of the bowels each assessment to assure there are not decreased bowel sounds?” I get kind of a defensive answer, like I am suggesting she is half-a$$ing the assessments, so I don’t ask those kinds of questions much anymore.

I realize there is a world of difference in ‘textbook nursing’ and ‘real-world nursing’, so it is a bit of an adjustment to listen to these tips and wonder about the disparity in how we are taught to do an assessment and what is done in the real world.

My orientation experience has been positive overall and we seem to be working well together. Other than situations like I mentioned above, we have good communication between us. She’s good at showing me procedures (ex: IV starts, ostomy care) and she’s understanding that time management is one of the most challenging things to get down pat.

I wanted to post this for discussion to receive some advice about how to speed up assessments and keep these patients on their time schedule without constantly feeling like I am going to miss something or overlook something.

[Imafloat, BSN, RN]

I usually do a very thorough assessment my first assessment. If I have 2 kids due at 8 I will start one at 0745, if one of the 0800 feeds is NG, I would do that one first. I'm a list person so I'll give you my list.

-BP

-temp

-feel fontanel, check cap refill on all 4 extremities while waiting for thermometer to beep

-listen to heart for full minute, count, listen for murmur,look for active precordium, listen at all landmarks, make sure that what I counted matches the monitor

-count respiratory rate for 30 seconds, make sure it matches monitor, listen to all lung fields

-listen for bowel sounds in all 4 quadrants. If I hear bowel sounds right off the bat, I move on to the next quadrant. If they are hypoactive or absent, it can take a long time to listen, I will listen up to a minute in each quadrant before I say that bowel sounds are absent. If this is the case, you shouldn't be feeding the baby.

-check pulses

-measure girth, and OFC if the kid is a daily OFC kid

-if the baby has an NG tube, I will do my NG placement verification stuff

-face wash, diaper change

You will be looking the baby over while you are doing all of this. You are looking to see the baby's color, is he pale, jaundiced, mottled...does he have bowel loops, is he retracting, is he warm and dry?

I may be leaving something off, it's been a long day! The next assessment I will take my vitals off the monitor, because I have verified the monitor is correct. I won't listen for a full minute, but I will do a quick listen in all lung fields. I ALWAYS listen to my babies heart, lungs, and bowel before every feed. I would hate for a baby to have no bowel sounds and to feed him! NEC can hit in an instant.

You will get quicker with time and you will develop your own system of what works for you.

[Moondance]

Thanks for the reply :) I also listen to all lung fields, all quadrants of the bowel and do RR for 30 seconds (6 sec is too short for a periodic breather in my opinion). It seems I am doing it right, maybe just with practice I'll pick up speed. In my unit, they don't measure girth, but we did at the hospital I did my internship. So I make sure I notice the abdominal shape carefully during assessments as well as palpate to check that it is soft, non-tender and has good bowel sounds.

[newohiorn, BSN, RN, EMT-P]

Thanks WeeBabyRN--I'm just starting to float to our NICU and I felt like a fish out of water tonight. Posts like yours are helpful for me to develop a pattern.

[Imafloat, BSN, RN]

Moondance, I also wanted to say, I know it's hard, but try not to let them rush you too much, it's your name going on the chart so you are responsible if something goes wrong. I'm a preceptor and I try to remember that when the orientee is going slower than I like. I give the orientee tips like check for cap refill and softness of the abdomen while waiting for the thermometer to beep. If you feel really rushed all the time, find a nice way to put it on the evaluation of your preceptor at the end of orientation.

[babyNP., APRN]

Like others have said, I definitely do a full assessment when I walk in, but after that...I only do a full assessment every 6 hours if it is a stable child on room air and eating. Every 3 hours I'll do a full set of vitals and listen to lungs, heart, and bowel sounds, change the diaper...

A lot of your assessment comes from just looking at the baby--is he breathing comfortably? Is he flexed normally? Acting appropriate? Looks pink...etc etc

[RM-RN]

If I have 2 at the same time, I also start with the less time-consuming patient. It might be because they're a faster eater, their parents aren't in for that feeding, they're all NG, they have less on-going issues, etc. Otherwise, this is kind of how it goes...

As soon as I'm done with report, I verify my orders and make sure that I know what I'm doing at my initial assessment. (My inclination is to chit chat, but I have to remind myself that I'll regret that choice later!)

Wipe down their bedspace with our cleaning wipes.

Gather all the supplies I'm going to need for both babies and place them at the bedsides, or make sure they're stocked already. This is another place where I'm confirming what I'm going to do before I touch the baby. I find that if I set out the things I know I'm going to need, I'm much less likely to have to backtrack or have things I've forgotten. This would include any medications I might need to give.

Confirm that whatever everyone is eating is available for immediate use. (This is something that has hung me up on several occasions! The right formula not available, breastmilk not thawed, etc). Then I prepare #1's feeding and I'm ready to go by 1945 at the latest. My goal is to be on to the next baby by 2015.

If there's something more time-consuming that anyone needs, I'll see if I can save it for the less-involved time. Say baby #1 needs a bed changed, or a bath and linen overhaul and they can have that done any time...I'll do it at a time when I'm not also trying to fit in 3-4 head-to-toe assessments.

The actual hands-on assessment rhythm will come with practice. Generally, it's not the time-consuming part. I would not skimp on RR or HR. Our policy is 1 full minute, but follow whatever your unit policy is. Palpating pulses and abdomens will get faster with practice. I move from head-to-toe once, completing assessment and cares on the way down. Something like...

-temp and inspection of all lines....clean/dry dressings, infusing appropriately.

-Auscultate lung sounds and count RR

-HR, sounds, PMI...if I haven't annoyed the baby into screaming like a banshee, yet. For bigger babies, I sometimes do this before I return them after feeding....when they're full and sleepy. You can spend a long time trying to comfort a larger baby in order to complete your assessment, when all they want is food.

-Bowel sounds. We can't chart absent until we've listened for 5 full minutes. If they're absent, it's probably not a 4:1 assignment and feeding in a timely fashion isn't an issue. :)

-B/P (moving to something else while it's reading)

-Fontanels

-Eye and mouth inspections and care

-Confirm NG placement, aspirate residual, confirm secure dressing

-Any daily measurements that are needed.

-Visual inspection of everything else outside the diaper.

-Brachial pulses.

-Femoral pulses

-Assessment and diaper care.

-Clean-up the mess I've made in the bed.

-Old gloves off, wash hands, new gloves. (this is when I'm doing that mental checklist of anything I might have forgotten.)

-Feed.

If they're all big babies, and they don't require as much hands-on cares, they can probably also stand to start eating sooner. So....Ill start my hands-on at 1930, and start nippling at 2145. We have a 30-minute rule on feedings, so I know I'll be done no later than 2015.

Most of it is just practice. Don't feel down about being slower than some other people. If something goes south, the other babies might have to wait a little. There's nothing you can do to change that sometimes. I certainly wouldn't cut back on your assessment.

It'll get better. :)

[littleneoRN]

I'm with most other on these things. Counting a HR or RR for 6 seconds is something I do for rapid info in a code, not on a detailed assessment. I usually do RR for 30 or 60 seconds and HR for 30 seconds. I do a full assessment every time because I find over time I have learned to fit in a lot of the assessment things as I'm doing other things (e.g. feel the fontanel and check cap refill while the thermometer is reading. Don't let your preceptor put too much time pressure on you. Babies, even stable Level II babies can turn a corner quickly, and your thorough assessment is what is going to help you detect these problems. You will quickly regret a quick assessment when you later find a baby quite ill and wonder if possibly you could have detected it sooner. Plus, if you're charting that you did something, you want to have done it. :) It sounds like you are on the right track and just need time to develop rhythms and routines that come with time. This sounds like a challenging schedule for anyone, with four babies feeding in the first two hours. Our Level II has kids due on all three hours, so....usually having 3 patients, you'd have a baby due per hour. This leaves a bit of time to chart and deal with miscellaneous tasks between feedings.

[LuvofNursing, BSN, MSN, RN]

moondance,

at the end of the day, you have to provide nursing care that you can feel good about, and as you get efficient with your time and with your assessments you will find that it doesn't take much more time to be thorough.

it's not worth it to save a few minutes if it means possibly missing something important.

you'll go home feeling much better about your nursing care for that day if you stick to what you know is right. your babies deserve that.

good luck to you.