What do you REALLY assess? Percussion? Palpation?

[BonnieSc]

I'm about to accomplish a major victory by instituting required AM assessments on the floor where I'm a nurse educator.

Before you gasp, I work at a hospital in Africa (you may have seen other threads I've scattered around the boards, looking for advice/perspectives). The RNs, some of whom even have bachelor's degrees, function at about the level of an LPN. Most of them were trained in assessment, but they very rarely do one. They're already required to do an initial nursing admission assessment, but it's really mostly patient interview and copied from the doctor's assessment, with very little nursing physical assessment happening.

I've taught assessment many times here now, to nursing students, and to the nurses of one floor where it did not end up taking hold as a practice. I know some of the pitfalls to avoid. But I also want to avoid creating a lot of mini-mes who assess exactly the way I do... if the way I do it happens to be lacking, so I want your opinions.

The students and their clinical instructors (most of whom are not particularly well-qualified nurses or teachers, unfortunately) always challenge me on my assessments. "You didn't do this! You didn't do that!" They have been taught to do an assessment that pays lip service to being extremely thorough, but is actually, to my mind, totally ineffective--not least because it's so complicated and takes so much time that no one actually does it. Also, they know WHERE to assess but have no idea WHAT to assess (so they can move the stethoscope around the chest, but don't know the lung sounds).

Anyway, I'm weary of being told I'm Doing It Wrong, but I'm curious if any American/Canadian/etc nurses do these things, as part of a regular daily assessment for the stable med/surg patient.

What do you assess? Not what did you learn to assess, or what do you think you should assess, but what's your actual daily practice?

It's hard for me to put into words because like all of us, I'm sure, I assess a million things without naming them. But my basic assessment is this: check pupils, lung sounds, heart sounds, bowel sounds; IV, ID band, pulses, grips, cap refill; ask about bowel movement; assess foley, dressings, drains, etc; check for edema and pedal pulses; assess BLE strength; check heels for pressure sores (and sacrum, if applicable); general skin assessment; pain; talk about anything bothering the patient.

I never do percussion. I never do true abdominal palpation. I don't assess the genito/urinary area other than the foley or some other obvious concern.

My philosophy on the shift assessment is that I'm checking for the typical complications of hospitalization (pneumonia, pressure sores, clots, constipation, weakness, inadequate pain control), looking for things that weren't given in report (surprise! Dressing on the right thigh!), checking that devices are working correctly, and doing a focused assessment on whatever the patient's being treated for.

Any opinions? Do you do more or less than this?

[ArmaniX, MSN, APRN]

I'm an icu nurse so my opinion may not help but every basic assessment should include a neuro exam w/ pupils. Lung/heart auscultation. Pulses (radial/pedal). Bowel sounds.

Skin/IVs/Wounds/Devices/drains as applicable.

The only time I'd see palpation to be required is if there is an acute issue but routinely no.

[Momma1RN, MSN, RN, APRN]

I work on a medical tele floor and for every patient I listen to heart, lungs, bowels. I palpate for tenderness in abdomen, assess for edema, and with all of this do a general once over for overall condition of skin. If it's a neuro patient I do neuro checks which include pupil assessment, hand grasp, arm/leg drift, strength in LEs. If indicated I check pedal pulses, but if i'm assessing for edema and their feet are warm, I don't.

[BonnieSc]

What's your rationale for palpating for abdominal tenderness?

[bestallaround, ADN, CNA, LPN, RN]

I once found an enlarged liver upon palpation.

[BonnieSc]

Was it something new that had developed since admission?

[Pheebz777, BSN, RN]

this is how I assess my patients:

First, assess responsiveness. Say "good morning Mrs. So and So.", if they respond in an appropriate manner, I'm good. If not, go from there. His or her altered mental status could just be caused by dementia, or more serious problems, elevated ammonia, CO2, or shock.

Next do a head to toe assessment. But before you do this.

Focus assessment on patient diagnosis. If the patient is admitted for pneumonia you would definitely want to listen to lung sounds. Observe rise and fall of chest, check for nasal flaring, use of accessory muscles, clubbing of fingernails. etc.

Ask the patient on his prior level of functioning prior to coming into the hospital. His / her activity level last month, last year, or even last week, or a few days ago.

Now that you have a basic picture of your patient, you can now do your head to toe assessments as you have already described, and now you know where to focus your assessments.

About your question on percussion or palpation, I only palpate the abdomen to find out if there is any underlying pain that the patient normally would not complain about. Then note those findings for the doctor when he rounds. Palpate any abnormal bulges that you see, especially for abdominal hernias or inguinal hernias and note your findings.

I only percuss the abdomen to find out if the abdominal distention is more of fluid, or air. From a nurses standpoint, there's no point in assessing in detail. Here in the US, if there is any pain or any abdominal problems, CT scans, KUBs or MRIs would provide more superior information than any percussion/palpation skill could provide.

Do this routinely and it's a peice of cake.

[BonnieSc]

Thanks everyone for the comments. I did my first teaching session today. I expected the comments about "we don't have time for this" (though my demonstration showed how quickly it can be done; I think they went into it with that attitude), but I didn't expect the nurses all to agree that it was a good idea, but probably what was going to happen was that people would chart without actually doing the assessment. I was floored by this. "Well... don't do that!" I said. One of the problems I face here is that people don't want to do "extra" work, and work is perceived as "extra" if everyone isn't doing it. So if they believe some of the nurses are faking the assessment, even though they THEY would "never" do that, they don't think they should be expected to do an assessment either. They never seem too impressed with my theory of "you can only control your own behavior". And instead of being proud to be the most advanced department in the hospital, they demanded to know whether the other departments were doing this too.