To Assess or Not to Assess...

Posted
by it'sallbueno it'sallbueno (New) New

..should NOT be the question! Anyone else finding in report that assessments seem to be optional? :o

Recent Examples:

--A foley cath that is endorsed in report, but actually dc'd the day before

--20 cm water suction for a chest tube actually bubbling away at 8 cm

--The inability to answer such questions as "What size is the trach?", "What's the pressure of the wound vac?" and "What's has the patient been doing on the monitor?"

What is up with this??? Have I just hit a run of knowledge deficit, or is this a new trend? (I have heard of nurses doing "problem specific" assessments -- looking at wounds and drains, but skipping the whole head-to-toe thing.) And if you do receive an incomplete or incorrect report, how do you respond to your colleague?

Incidentally, I have an appointment to speak with my nurse manager about this on Monday...

NeuroICURN

NeuroICURN

Specializes in Neurology, Neurosurgerical & Trauma ICU. 377 Posts

Yikes! I agree with you....there's nothing I hate more than a sketchy report! I have to say that just about everyone in our unit gives a VERY detailed report....but with the occasional float pool person or traveler that doesn't know how we like things, sometimes you have to probe for the information.

First, let me preface what I am about to say by telling you that when it comes to my work, I am VERY anal retentive. Ok, that said. When I give report, I give it in a specific order (and almost everyone gives it the same way I do).

1. Patient name, age, admitting MD, consulted MDs

2. PMH

3. COMPLETE story about why they are there and dates that things happened. (i.e. "On 8-6 patient was found down at home, unresponsive. Patient taken to outlying hospital, CT showed left ICH, Life Flighted here, intubated en route, CT here showed..... On 8-7 pt swanned., etc.) Just so you all know....I just made that stuff up! We give dates for anything significant that the pt. had done, including line placements, drips started, testing, etc.

4. Now we go through each system of the body and what they are doing with each. NEURO, RESP, CV, GI/GU, LABS. For neuro, it can get very detailed, including what they do to verbal or central stimulation, if they have their protective reflexes and which ones, pupils, etc. Resp: vent settings, resp. rates, sats, tube size and placement (or trach size), etc. Now, if someone leaves something out, then I just flat out ask. I've been giving and getting report for so long that I know immediately when something is missing....also, we usually do it right in front of the pt's beds, so you can see the pt.

5. Then we talk about any family issues or anything else of interest that needs to be passed on.

6. Finally, we go through EVERY order that the previous shift was ordered and tell if it was done or what needs to be done.

Even when I give report to the floor, I give it the same way....even though they usually don't want that much information! LOL :rolleyes:

Now, as for receiving misinformation....well, it happens, but pretty rarely. Only because our charting is sooooo extensive and it's hard to chart without lookin at this stuff.

I can understand how frustrated you must feel. I think you're doing the right thing by bringing it up with your NM....but did you also discuss it with your charge nurse? What did he/she say? Is anyone else experiencing this too?

Keep us updated!

NeuroICURN

gwenith

gwenith, BSN, RN

Specializes in ICU. 3,755 Posts

I personally don't like "assement" I prefer "continuous evaluation" which makes oversights like the one you reported even more glaring. The idea of continuous evaluation is that when you look at your patient you are relying on the information gathered by previous shifts and passed onto you.

CC NRSE

CC NRSE

96 Posts

i agree. of course tell me the pertinent information (they do have a foley, trach, ect.) but don't tell me breath sounds, opinions on family ect. i will figure that out soon enough and had rather have "just the facts". as far as neuro, (i realize it is different if you have more than two patients,) but i personally like to do a bedside assessment with the oncoming nurse so there is no questions as to what is new and what has been. only thing i want to know regarding an assessment is if something is abnormal and has been that way. that way i am not calling the md about something he/she is already aware of. (no pulse in r foot, cool to touch but no pain, been that way for 10 years!!!)

jschut

jschut, BSN, RN

Has 20 years experience. 2,743 Posts

Haha! I would LOVE to have such a thorough report on a new patient....I get things like...

reporting off nurse: "And Mrs. So and So is doing fine today."

Me: "Oh! She's came back from the hospital today?"

reporting off nurse: "Uhhh..oh...no...I guess not. I haven't seen her."

HELLO!?!?!?!?!?????? DUH!!!!! :eek: :eek:

NeuroICURN

NeuroICURN

Specializes in Neurology, Neurosurgerical & Trauma ICU. 377 Posts

That's scary Julie!!! :uhoh21:

transplantnurse

transplantnurse

4 Posts

That's scary Julie!!! :uhoh21:

I spent 9 years working with open heart patients. I saw EVERY pt. during the first hour of the shift. I did a cardiac and wound assessment on EVERY pt. What if their lungs filled up after a meal? Would you have anything to compare it to if you didn't assess them? I never understood these nurses who would say at 1000. "Oh I haven't seen them yet"". I've had too many people go bad in too quick of a time to risk NOT assessing everyone at the beginning of the shift.:angryfire

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