It’s been 5 months since I started on the med-surg telemetry unit and it’s almost time to come off of probation! One of the nurse educators watched two of my head-to-toe assessments and me giving out medications (satisfying the 5 rights for a PO med, SQ injection, intravenous med, and narcotic).
I remember one of my first nursing school classes– doing the entire head-to-toe assessment in 10 to 15 minutes and stating each finding. That was probably one of the most important classes because it’s now kinda easy to recognize something abnormal.
Especially for a cardiac patient, pedal pulses, edema, lung sounds, heart sounds, and neuro checks are important.
Bowel sounds and asking for the last BM is important for surgical patients or for constipated people.
Skin checks at pressure ulcer points (sacrum, heels, back of head) are of upmost important, especially for bed bound and incontinent patients. Is it red? If it’s red, is it blanchable (turn white when you push it)? Could it be a stage 1-4 or a deep tissue injury?
Surgical sites should be monitored for bleeding, leakage, etc.
Urine output of a minimum of 30 ml/hr is also important, especially for those who have a foley! But even knowing how often patients urinate is important. If they haven’t gone all day, then it’s a problem!!
Anyway, I could go on and on. But for right now, here’s an example where the assessment made a different (and trust me, there are many, many examples).
A patient was having a productive cough and felt like he was having a hard time breathing. His O2 sat was 94% on 2L nasal cannula but his lungs had crackles (it sounded wet!) bilaterally (on both sides of his lungs). His feet were puffy (or +2 edema) although pedal pulses were palpable. After calling the PA, I got an order for IV Lasix — which basically works your kidneys to draw in the fluid and excrete it through your urine. Throughout the rest of the night, the patient continued to cough, but his lungs began to sound better. However, due to his surgical site, he experienced a lot of pain too. While I gave him pain medications according to the orders, I noticed that the patient started to get a little more confused by the end of shift. This is when I had to start questioning the type of pain medication given. When giving report to the day shift nurse, I made her aware of my findings. Because of that, she was able to talk to the PAs, NPs and MDs on the floor who are more readily available during the day and make an appropriate decision to treat his pain without him getting confused.
Anyway, I passed the head to toe assessments and giving out medications portion. Now, there are two sections left.
1) Code master, setting the IV pump, and doing the appropriate medication calculations
2) 50 question EKG test with a > or = 90% since I’m on a telemetry unit. It wouldn’t make sense to work there if I can’t read the rhythms. Even though each month I have to pass a 30 question exam too, they still want us to pass the 50 question exam. It’s ok– I’m ready anytime. 🙂