What do you assess?

I have always worked cardiac or ICU.

LOC

Apical heart rate and sounds

Lungs

Bowel Sounds

Pedal Pulses

for edema pitting vs non pitting.

on all patients.

Hi Everyone,

I was just wondering what you all assess in each patient? Do you do the same assessment on every patient? Just assess the issues the patient has been admitted for? Head to toe?

Sometimes I feel like an idiot asking a patient with lower leg cellulitis if I can listen to his lungs!

Thanks for any input!

I do a head-to-toe assessment. For me, I like to know the baseline I'm working with, and it makes it easier to pick up on a change in the patient's status. It also helps to compare to previous nursing and physician assessments. For example, there have been occasions I hear rales, but note the doc charted lungs were clear that morning; also noting I&O, VS, weight and any other signs of retention, I'll call and get orders for lasix and/or a reduction in the IV rate.

As far as cellulitis of the legs and lung sounds... that person is at risk for PE. Even if I were doing a focused assessment on that type of patient, it would still include a CV and respiratory assessment.

:yeahthat:

Part of my facility's standard of care is that each patient has a full head-to-toe assessment by an RN in each 24hr period. This is usually done at midnight. I usually start my shift with head-to-toes, around 8pm, so I know what I'm working with. Usually, I make that first assessment a thorough one, and if skin integrity is good, I don't roll them around at midnight. At 4am, I do a focal assessment with neuro checks, heart and lungs, and whatever their particular problem is. If the patient has been neurologically intact, I sometimes "disguise" my neuro checks by asking about pain and whether they need anything, and I'll skip the flashlight in the eyes if they appear equal.

Working on a neuro unit, I'm pretty religious about neuro checks, so I get some funny looks when I'm floated to another unit or have an off-service patient on mine. Still, I figure if a patient with a fractured femur can't tell me who they are, it's something we need to know.

I have had shifts where about all I could do was assess another system each time I put a patient back to bed, then sort of tie them all together into one full assessment.

ETA: Being male, I tend to approach female patients from least personal to most personal, rather than top to bottom. By the time we've done orientation questions, extremities, heart, lung, and abdomen sounds, it usually doesn't seem quite as intrusive to ask to see any dressings or their backsides. And if the patient is at all oriented, I usually explain what I'm looking for and why during the first assessment. I do try to find a balance between patient comfort and my need to do a good assessment, and sometimes it helps just to know why I'm playing with their feet.