Thoroughness of your 1st assessment of the day

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Hello everyone,

For people who work in acute care: I would like to know how thorough your first assessment of the day is. I started in acute care about a month ago and I am very concerned at how shallow my assessments are compared to what I was used to in private duty nursing. Nowadays, I do not have the time to ask as many questions or see all their nooks and crannies from head to toe first thing in the morning. I feel very uncomfortable when I don't see a patient's stage 2 on their coccyx until noon. That kind of thing. If (key word if!) I do feel complete with my knowledge of the patient's body, it is not until the end of the shift when I have asked, poked and prodded enough in piecemeal.

Plenty of more experienced nurses say an assessment should take you 90 seconds. Eep. In that time frame, I can only safely ascertain they're alive and not about to crash. Maybe that's enough... I don't know. I am far from the point of agreeing with that statement.

I sense that this is just a transition from one area of nursing to another. I would like some insight into how you conduct your assessments on acute care patients, at what point do YOU feel safe in your knowledge, how long did it take for you to find a "system" you felt comfortable in. Also, I would love tips and tricks to get the maximum amount of assessment done in the minimum amount of time.

Thanks everyone!

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Followup question: We do q4h assessments. Do you think it is understandable/acceptable to leave out, say, the integumentary portion at 0800 but follow up with a more thorough one later during the day?

I guess integ is my word of the day. Had a few patients with skin issues and felt bad not addressing them the way I could and would at my old job.

Thanks again!

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Specializes in Emergency & Trauma/Adult ICU.
Followup question: We do q4h assessments. Do you think it is understandable/acceptable to leave out, say, the integumentary portion at 0800 but follow up with a more thorough one later during the day?

This may be acceptable - it was when I worked full-time in an ICU - but you'll need to check your unit's policies.

Give yourself a little time to get acclimated. I bet it really doesn't take you a full 90 seconds just to make sure a patient is alive and likely to remain so in the short term. As you're walking in the room you assess color, respiratory effort and monitor rhythm if they're on the monitor ... that combined with whether or not they're alert and make eye contact, or at least at their baseline mental status, and a quick touch on the arm to feel skin ... tells you you're good to go for the moment. And that's about 6 seconds. ;)

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Usually you assess what is asked for in your assessment forms that apply to your patient.

Sometimes you will not see the cocxyx until later because the patients that require Q4 hr assessments cannot just turn themselves, and getting turning help is difficult at the busy 0800 assessment time.

I will do a through inspection of the back side first thing if there is something critical I need to see like an epidural site, otherwise a patient with no known skin issues can wait a bit.

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Give yourself a little time to get acclimated. I bet it really doesn't take you a full 90 seconds just to make sure a patient is alive and likely to remain so in the short term. As you're walking in the room you assess color, respiratory effort and monitor rhythm if they're on the monitor ... that combined with whether or not they're alert and make eye contact, or at least at their baseline mental status, and a quick touch on the arm to feel skin ... tells you you're good to go for the moment. And that's about 6 seconds. ;)

Touche, touche.

I bet if I did time myself I would have gathered half of what my hospital's assessment forms asked.

Thank you guys for the reassurance.

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Specializes in Cardiac, PCU, Surg/Onc, LTC, Peds.

Sometimes I won't see their behind if i cant turn them by myself but I always see their backside within the 1st 2 hours. I don't think your employer would be very empathetic if a pt had a serious new HAPU and you didn't document it until the end of your shift. Just saying.

We chart by exception one full assessment PER shift, if they're changes during the shift we would add those when discovered. I have worked other facilities where the assessments were Q 4 and the 1st would be a full assess and the rest focused assess.

I wouldn't expect a new grad to be able to fully assess in 90 seconds but yes it can be done quite easily with experience.

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