Why aren't we assessing patients?

[bluebelle0604]

I had a pt who was admitted two days prior and I told her I was going to take a listen to her and I did my full assessment (which is a focused assessment, however I always listen to the lungs, heart and bowels). Afterwards she thanked me for doing the assessment and stated that I was the only one who had assessed her since she was admitted. I was shocked and I went through the past assignments to see what nurses had taken care of this pt and they were all very experienced nurses. This pt was a young women and appeared to be fairly healthy, however, I never skip an assessment. That is one of our main objectives...to assess the pt and base care off of the assessment. Anyway, what do you all think? Is this a common problem? Should I have talked to my managers about it?

[blackvans1234]

Too much ''more important stuff". I know that my bosses don't have unit meetings about assessments, just the latest 2 more interventions we have to document on each patient, oh yeah, and the white board.

Too much busy work, not enough taking care of people.

[blackribbon]

One of the first "time management" skills I was taught on the floor was how to cut and paste the previous shifts assessment. I refused to do it and was constantly being questioned about how long it was taking for me to do a head to toe assessment. I couldn't figure out how so many nurses were "done" so quickly. I now know. Before they start pulling meds, they cut and paste the previous shifts assessments.

I am always the last one to finish passing meds because for many cases, I want to do that assessment BEFORE I actually give a med. I can do it in just a few minutes if I don't find anything strange.

Personally, I am amazed by how many patients have odd charting..just this week, the lady who had right sided paresthesia/paralysis related to a stroke...who was charted as "steady gait with support". I helped her to the bedside commode multiple times and I don't think she used her right leg for anything but balance.... steady gait???

I am most upset by the number of people who don't have vital signs charted before being transferred to my unit. A week ago, I had a patient arrive and my aide came and told me that her BPs were 250 over something according to the machine...she asked if she should chart them or wait for me to do a manual. I did the manual. I got 212/112....then looked to see what her trend was. NO BP had been recorded. I called a rapid response .... although she was asymptomatic, she was having an active brain bleed. She was still asymptomatic when she transferred off my unit to MICU but I saw that 2 days later, she was non-responsive. The hospital did do an investigation and it turns out that everyone just handed her off not believing that the BP numbers were accurate...so no one recorded them or thought to say anything to the next person. She looked "okay". She was admitted for nausea and vomitting. She told me that they had told her that "something must be wrong with the machine because dehydrated people don't have high blood pressure." This week I got a new admit with a temperature of 103.6...which quickly increased to 104.5. Again, last recorded temperature taken was many hours prior. Her charts were filled with notes about sending her home if she could tolerate clear fluids. ???? Maybe it did spike but without any recorded trending, I have no idea what was going on before I got her. She was obviously running a fever when she arrived on my floor without even putting a thermometer in her mouth.

[PacoUSA, BSN, RN]

I personally do not have a problem cutting and pasting an assessment if we have that capability.

That being said, I need to clarify that statement before I get flamed: after I cut and paste though, I ALWAYS review what I pasted and make changes accordingly. I do not and I repeat DO NOT blindly cut and paste without review. Charting is way too time consuming, especially given the high patient ratios on the units these days. If you're gonna give me 6 patients, I'm surely not going to sit there and click click click if I can cut/paste/review when there are more important things to do in patient care. I don't consider cutting and pasting a shortcut, rather it is efficient use of time management. However, it must be used correctly! If I cut and paste, I'm certainly not going to cut and paste someone else's free text. I delete and write my own.

The wildest assessments I've seen (since you can see the prior shift's assessment in the next column):

+2 pedal pulses bilaterally (patient is a double BKA and no femoral pulses recorded, nor was this field wrenched in).

Abdomen flat, soft, not tender (patient is morbidly obese and dx is pancreatitis)

Lungs clear all fields bilaterally (patient hx of lung ca and had rt lobectomy)

I don't know who designs these charting programs, but they are obviously people who have either never been at the bedside or who haven't been there in a long while. There have to be more efficient ways to chart. I have my own ideas and hopefully I can help implement them later on should I decide to go into informatics.

And YES I always assess my patients!

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