I just finished reading a post on allnurses.com. The question was “Assessments Every Shift?” The consensus from the 40 posts was: “Yes, you cannot be too busy to do head to toe assessments.” Yet, there were horror stories about no assessments being done because of how busy the nurses were. My answer would be. “Yes, nurses need to do assessments every shift, but they don’t have to be head to toe assessments with every patient.” Here are some suggestions about how to get the appropriate nursing assessments done no matter how busy you are.
Follow the nursing care plan
Each patient should have had an initial/admission nursing assessment. This is the time when a head to toe assessment is critical. Then diagnoses were made with accompanying goals and interventions. Now it is up to you to evaluate daily whether these interventions are effective in progressing toward the goal. The nursing care plan should guide you to what nursing assessments need to be done on your shift. Every patient does not need a head to toe assessment but an assessment focused on the nursing diagnoses identified in the care plan. For instance, a new post op patient with an IV and foley catheter will be at risk for pneumonia, wound infection, IV infiltration, DVT, skin breakdown, constipation and pain. The questions and exams the nurses do will focus on these areas.
In addition to following the care plan, there are issues with patients that develop day by day. If a patient has a change in condition or a possible complication, this is the first patient you are going to assess. If several patients have changes, then you decide which ones are the most serious. For instance, a patient with a fever would need attention sooner than a patient with a sore toe. If there are no pressing issues from report, do your best to make quick rounds on your patients to introduce yourself and make sure there are no impending crises. Preventing a problem is always preferable than having to deal with an emergency. Reality is, that the sicker patients are going to need more of your time than the patients about ready to be discharged.
Take every opportunity to assess
Every interaction with the patient gives you an opportunity to ask questions and do focused exams.(In other words, do an assessment) During the medication pass or while doing treatments are good times to see how the patient is feeling and do a quick exam.
Lead your team
Take advantage of delegating some information gathering to your nursing team. CNAs can take vital signs and report changes in patients’ conditions. LPNs can make observations to obtain both subjective and objective information. They just can’t analyze that data and make a nursing diagnosis. That is up to the RN. Make sure as the leader of your nursing team that everyone knows and follows the nursing care plan.
Using these suggestions, you can save time and effort. By following the nursing care plan, you will know what nursing assessments need to be done on each patient. You will never miss a change in condition and will deliver the best quality of care to your patients.