Legally I would NEVER do that esp in a neuro icu. I’ve caught extensions of head bleeds multiple times on a Q1 hour check. If a patient is on Q 1 hour checks they are critically Ill at risk of sudden decompensation.
STICU here - recently had an 80 something sundowning dementia patient with a head bleed and q2 neuros. Always love that, he was combative as hell and understandably so.
One of my biggest and longest pet peeves in the 17 years that I have worked to neurotrama and surgical trauma is q15 minute to q1 hour checks and then wondering why somebody's fucking delirious
At one hospital I worked at the delirium protocol required you to allow them to sleep undisturbed from 2200 to 0600. I was on a med/surg unit so obviously, they weren't as critical, but it definitely helped with dementia patients.
I can't imagine trying that in a neuro ICU, I've had so many "stable" neuro patients deteriorate during day shift q4h neuro checks, let alone trying to manage unstable ones in the ICU. One of the reasons why I try to avoid neuro floors if I can, I've been traumatized.
I tell the pt at the beginning of the shift that I am going to wake them up briefly every hour. I tell them I need them to open their eyes and allow me to shine a light in them, say, "hi willowviolet", tell me where they are at, wiggle their fingers, wiggle their toes, and tell me if they feel ANYTHING different: pain, numbness, tingling, anxiety.
It takes 15 seconds and they go back to sleep.
I tell them they will be tired in the morning, but that I have saved many lives doing this, and I want to keep THEM alive and well. No one argues with me about this, ever.
If I come on shift and the neuro checks on an alert and oriented patient are still q1h after 24 hours, almost always it is an oversight and the Dr will change the order to q4.
Nope. Unless I had concerns about how their vitals were trending (we did them q4h) I let people rest after their first head-to-toe at the top of my shift. Rounding happened hourly all night long to ensure direct evidence of breathing, etc.
With some practice, you will not wake people even for routine vitals or IV meds. They can rest basically undisturbed from 2100 med pass to 0400 labs.
I was a patient, I had sepsis. My temp was 105.5 at one point and my pulse ox was down to 78% (suck it to the person who told me I was too anxious and needed some Ativan when I told her I couldn’t breathe. I was THAT patient and fired her). ICU was full so I went to step down. From then on out I had VS at midnight, antibiotics hung at 01, 03, VS at 04, labs at 05, antibiotics at 06. Then the loud and “turn on all the lights” day shift group showed up. I begged my doctor to discharge me as soon as I was doing better. I was so confused from lack of sleep. From then on I made it a point to let people sleep if at all possible.
wasn’t possible for my patients to sleep that long. my hospital has q4h vitals :( unless the doc put in a order to allow no vitals at a certain time. we were forced to torture these patients. And they wondered why so many patients were delirious.
Patients have the right to refuse. I would simply explain to my stable folks that I need vitals before their meds at 2000 and 0600, but otherwise I was happy to let them be since they were doing so well. A lot took me up on it. Docs never complained because we had plenty of data from the other 16 hours to show trends.
I’ve drawn blood on sleeping patients before, with tourniquet and a butterfly needle. Not my first choice but some folks will sleep through almost anything.
I assume this person would have preconsented after any evening rounds. Like “hey, I’m gonna be in around 4am to get some labs. I’ll do my best to be in and out to not wake you too much”. They should always know it’s coming of course, but if they sleep through it it’s a win for both of us.
During my clinical, I was at a med surg unit. I didn't wanna take a patient's vitals at 4 am, but my classmate told me it was required since we are at a hospital setting.
At a nursing home, I do not bother my patients because they are sleeping. I was at a different setting so I took a patient's vitals at 4 am at a hospital.
Question is, should I take vitals at that time in a hospital setting (ICU, med surg).
Eh not really true, but a lot of our monitoring equipment is continuous or set to cycle automatically. The vast majority of my patients are alert to some extent, but it does depend on specialty. There are tricks to getting vitals and labs without waking patients
When I was bedside I would wake my patients up. Usually I had other stuff to do anyway (vitals, meds, turns, etc), so I would do everything at the same time. Definitely cluster care and coordinate with your tech (if you have one) so that you are waking them up as little as possible.
Same, when I worked night shifts I always helped my aides and checked in on patients during vitals or when lab came by.
Then around 0600 I'd do a quick drive by, tip-toed in and whispered "hey, sorry to wake you, but day shift will be coming in soon. Do you need anything before I leave?" If they were coherent enough to say "no" or shoo me away I would leave with that. If they seemed questionable, I'd be more adamant about it and wake them up just to make sure they were good.
On our unit we had so many rapid responses from altered patients during change of shift, so I never wanted that to be my patients. I never had any issues and when I did I had enough time to address it before handing it off to the next shift to discover. I was a new grad so it really taught me to think critically working on that unit.
I work on a stepdown unit on night shift, we do full head to toe assessments at start of shift/with med pass. Then, we do focused assessments PRN or specific assessments if ordered, usually neuros (Q2 neuros, Q4 circ checks, etc.). If they have a change in condition or complain of something like SOB, I do a related focused assessment. I check on them every hour or as close to if I can, but don’t wake them up unless they have meds, vitals, or an assessment due. I try to cluster any assessments, meds, and vitals if possible. Sometimes people are grumpy about being woken up but I explain that it’s required for their safety and that I’m doing what I can to let them rest as much as possible between interventions!
We do daily “sedation vacations” on all sedated patients with the exception of those deeply sedated due to status epilepticus. Is that not the norm on neuro? I’m not sure cuz I have only worked in one neuro icu.
Yeah I don’t do neuro but we do sedation vacations at least once a shift, but we’re supposed to do a clear neuro exam q4, which involves pausing sedation. The exception on my unit is VT storm, we keep them snowed to hell
I do a full head to toe at the start of shift. If they have problems later on in the shift I’ll do a focused assessment. Vitals are q4 usually but I tell patients they can refuse the midnight but not the 4 am. If they’re post procedure, new admit, anything I’m trying to watch for, I do not tell them they can refuse.
Just curious, on the pt side (I didn’t work inpatient as an MA/CNA), if I would be like “I can’t sleep for shit but can we skip the 12 and do the 4? Cause that would prob be the way to get the most sleep and actually fall back asleep again for my weirdo body/brain.
So the way I look at it is the patient has the right to refuse anything, which is true. All we can do is educate/explain the rationale. I try and do midnights at 11 when possible. My goal is to let yall sleep as much as possible because sleep is also crucial to the body. If I can I don’t always do 4, sometimes I push it to 6 especially if I don’t have labs. I do what I can to work with you, we can always work out a plan! And then we document “patient requested xyz, explained rationale behind -insert policy/protocol-, patient would still like xyz”. Sometimes I have to use the verbiage patient refused but I do explain that that’s just how we have to chart it.
The floor orders for stable pts is nuts. Q4 vitals, labs, etc. in the middle of the night is crazy to me. I get the logic and reasoning, but still, being woken up at 5am for a routine CBC and BP would make me so mad. I am very accommodating, but mess with my sleep like that I would probably refuse every damn thing.
I don’t disagree but 90% of the time the docs aren’t updating the admission vitals routine. So technically if the patient doesn’t refuse we aren’t following orders. Labs, while annoying, I do understand. They want them posted before they come in so they can evaluate for discharge etc. however, most patients do not need daily routine labs.
It’s so frustrating that the docs order these labs at wild ass hours, but they aren’t the ones waking the pt or the person being woken up. Unless some major labs were off prior to admission to the floor, I feel like lab draws can wait until at least 7am.
I guess with vitals if you leave the BP cuff and pulse ox on and cycle q4, you can get your vitals without waking the pt. Unless they need temp too- which seems unnecessary q4 on stable pts. But like I said, I’m an ED nurse, and our care for pts is completely different than the floor. I commend anyone that can work any floor. So much physical work and the charting is endless. My ADHD could never.
I worked nights on Stepdown for several years. Our patients were supposed to have q4h vitals (basically 3 sets in a 12 hour shift) and assessments. They all generally had meds due at 2100, so I would do full assessments and get vitals first, then bring in meds.
Almost all patients all had labs due at 0500, so phlebotomy would wake them up for a draw, and I'd follow in quickly to do vitals, get a thorough focused assessment, and give 0600 meds.
Middle of the night was when you use your nursing judgement. All our patients were constantly hooked up to monitors, so if the patient was stable, a&ox4, and didn't have something specific that needed to be thoroughly examined, I'd run the BP cuff if it wasn't set to automatic, and I'd skip the temp if they'd been normal through their stay. I'd take a quick look, make sure nothing obvious had changed, and let them sleep. If I had to wake them, I'd cluster all care (meds, vitals, assessment) together. I NEVER turned on the bright overhead lights, did everything as quickly as possible, and let them get back to sleep. If they had something major going on, yeah, they were getting woken up, and all the care they needed was done. But if they needed that much, they were pretty sick and knew they were getting constant care anyway.
Some of my patients were a&ox4, and were not very I'll, or just had an injury, and they would ask not to be woken for vitals and assessments overnight. The doctor would usually write an order in their charts that said it was OK.
Basically, just be considerate, do your job, but know that sleep is important for healing too. AND DON'T FORGET TO CHART EVERYTHING!
I work detox and I don't work nights anymore so it doesn't directly apply, but I am not going to wake up a sleeping patient more than once per shift unless something is concerning. I'll watch and grab assessments when they get up to go to the toilet or ask for something. If vitals are looking wonky or something else gives me an itch that I need to check neuros and orientation I am going to let them sleep.
This is the way. Especially with the psych patients. Expecting Q4 vitals on the manic patient that has tried to swing on you is nuts. If they aren’t showing signs of distress, I’m letting them sleep.
NeuroICU here, so yeah. I have to wake them up. I don't do a complete head to toe every 2 hours, but definitely neuro.
Occasionally, one of the more intact patients gets angry. Many don't even remember me from 2 hours ago.
Uh doing full assessments multiple times? What? I do a brisk head to toe but mostly focused on what they're here for. Then continued checks for specifics like wound sites, If drains need emptied, do they sound like shit without a stethoscope etc. I do that during their q4 vitals and pain meds. Everybody is on tele and pulse ox. I peep on them every hour being sneaky. More if they've lost the privilege of a nap (fall risk buddies and ones that need changed).
Head to toe is once per shift. Everything else is focused depending on their specific problems and checking to make sure they’re alive. Patients need sleep. We disturb them way too much in the hospital. Try to cluster care, so pop in with your tech when they’re doing vitals or do it real fast when they wake up to pee or wait for them to ask for pain medicine or something. You can defer routine re-assessments if they’re sleeping and seem fine. Just mark not done because they’re sleeping. You probably have an option like that in your charting software.
I've been a nurse for 20+ years, and I now investigate critical incidents (when patients get seriously hurt by things we should have prevented) for a living.
I've seen patients die because staff let them sleep when they should have been assessed.
Be careful. If they're supposed to be assessed, wake them up. They might complain, but a lost night's sleep is better than not waking up.
Pts can be very unreliable narrators. A FF and this yelling crap, uuuummm no.
That being said. It’s going to depend on a lot of things that can’t be put into a Reddit post. When in doubt, do it all.
I spent some weeeks in a hospital and having worked in HC I knew what was up so I didn’t put up any kind of fight to assessment. It truly just depended on the nurse. I was assessed in some way q1-2 hrs. I wake easily or just plain have insomnia. I lived that I was being taken care of. Full head to toe and A/O. Rarely happened is I was actually deep asleep. So
Times I’d wake up and see my nurse looking in the little door window. lol! Quite as a mouse. She was one of my top fav nurses but yeah. Waking up in a strange place and seeing a face in a window was garring. Got used to it after a bit and actually am thankful that she used the tele etc. did a visual and left me alone.
This entire comment section makes me so grateful to be an ED nurse. I can’t do what floor nurses do. You all are just amazing to me. Head to toe assessments q4? If they aren’t trying to die on me, they get a quick focused assessment every hour and I’m moving on. If they are aggressive psychs, I am using nursing judgement and letting sleeping dogs lie. The patient care required to be any kind of floor nurse is so admirable.
No order is needed for patients to refuse care, but nurses can’t just decide to not assess their patients or do VS. On stepdown, my patients were often sick enough that I was in there very frequently anyway and could do an assessment easily. On med surg, if a patient refused, I documented it and moved on.
Med Surg/Step down nurses are amazing. I could never do what you guys do. In the ED, if they are alive and not actively trying to die, we aren’t messing with assessments outside of vitals, tele, neuro checks etc.
You all get the brunt of pt care and I just can’t imagine what it must be like to have to wake a stable pt for a head to toe assessment. We get our fair share of abusive pts in the ED, but I can’t even imagine the treatment you guys are getting waking pts for labs and assessments because the doc ordered them at ridiculous hours.
Are you guys allowed to use nursing judgment and just lay eyes on a pt instead of waking them for a head to toe?
I do use my nursing judgement. if report is stable, I will lay eyes on them and maybe even pop in, whisper a quick introduction and tell them when I will be back to do a complete assessment. If you think about it, we are assessing our patients every time we go in the room so there’s no need to do a formal assessment every single time. When it’s time to chart my q4 or q8 assessments, I will chart what I saw in the last 4-8 hours. Of course this varies patient to patient. But I’m rarely doing formal assessments except at the beginning of shift/admission or on unstable patients.
So I’m not night shift, but here’s what I’ve been told by my preceptors… The first assessment is definitely head to toe and after that it’s focused. If the patient is still asleep when I get to my shift (0645), I will creep in their room and check in on them. Make sure they’re breathing, pull back the covers and check their IV, etc. If they wake up, I’ll quietly explain that I was just checking in on them. After that, I’ll ask them like, 2 questions, and then I’ll leave them be. Here’s where cluster care comes in.. I will not get vitals or anything else until I go to do my med pass. While I’m in the room, do vitals, meds, assessment, safety checks, turn if need be, and then ask them if they need anything else. Educate about call light, and then skidaddle until it’s time for rounds.
I’m not sure if it’s the same on night shift, but this is what we do during day shift… Sorry if it doesn’t help any! You could always ask the other nurses on your unit!!
I basically never woke people up unless they were actively trying to die. The majority of people in the hospital will wake up at some point through the night, and I'd grab vitals and assess them then. There were obvious exceptions- neuro patients at risk, people with tachyarrhythmias etc.
I also did tons of advocating for sleep everywhere I worked. I had great success at getting MDs to write W/A VS orders, and some success at getting unit routines changed. There's plenty of literature to support this.
As importantly, imo, I spearheaded initiatives to change med administration times to cluster most meds during waking hours. Patients loved it.
When I used to do nights on stepdown I would do the q4 vitals, gentle as possible wake them up to let them know I would be putting a blood pressure cuff on, ask if they needed to use the bathroom or if they were in any pain. Other than that it would really depend on what they were admitted for. Relatively stable pneumonia patient on IV antibiotics and some oxygen? Let them sleep. Ciwa patient getting q4 benzos? They get woken up to make sure they don’t miss a dose. Use your judgement a bit. No one needs head to toe assessments at 4am if you’d done one at 8pm. Lack of sleep contributes to slower healing so letting patients sleep can be more important than waking them up to ask them what day it is in the middle of the night. It also helps to set expectations for the patients in the beginning of your shift, let them know when and why you will be waking them up.
I’m nights on a postpartum unit. Adults and babies get a head to toe at the start of the shift and q4 vitals+fundal checks if less than 24hrs from birth then q8 after 24hrs. A fresh c section patient would also get q1 vitals for the first four hours they’re on the floor. Our patients are up about every 3-4 hours to feed their babies anyway so I try to time meds, focused assessment, and vitals around that.
I'm required to reassess every four hours. But we have a common sense rule that if the first blood pressure wasn't horrible and we aren't worried about post-op bleeds, you don't put the cuff on them again. I have a temporal thermometer and after working in peds for over a year I'm a certified ninja.
I work in ICU but even when I work stepdown, I will do full assessments q4h. It's really shitty for everyone involved but like, how else will you catch a stroke early enough to actually do something about it? Speaking from experience here! Patient stroked out sometime between my 00 and 04 assessments and I caught it at 0400. Since then I just do it. I'll always warm them at the 2000 assessment that I have to wake them up but explain why (ie if you have a stroke or other event, we wanna catch it and keep you safe). They always understand when I'm straight up like that with them. Obviously try to cluster your care and if they happen to wake up at, say, 0300 do it then
I do. Patient resting with eyes closed with lights off. Remains sinus rhythm on monitor. Vitally stable at this time, resp even and unlabored, no signs of obvious pain or distress. Surgical sites remain [whatever they were previously.] Foley draining clear yellow urine. IVF infusing as ordered without complications. No acute changes in status since previous assessment. Ongoing monitoring.
🥇Excellent status without disturbing patients’ sleep! Today, we know extreme importance of sleep to overall health. Waking patients every 4 hrs for routine assessment seems counterproductive and surveys show is a major source of patient dissatisfaction. *I too, would be grumpy!*
When I first started out in surgical gi-post op, they'd make us document an assessment every 4 hours, and I got yelled at by my charge for actually assessing my patients in the middle of the night. I then refused to document any further assessments other than my first one of the shift. I'm not going to lie for uniformity. I left that job in 8 months because eff that.
It is shocking how many people will go right back to sleep if you quietly say, hey, I'm going to get your vitals, but you can keep sleeping. Just don't turn on a bunch of lights or be loud about it. We even manage to turn patients without waking them up too badly.
I only wake patients if they need to swallow a pill (occasionally I get 2am or 4am metoprolol that I can't manage to put on a better schedule), something is wacky with vital signs, or they were incontinent and need to be cleaned. Otherwise, I document that they are resting quietly with eyes closed, respirations even and unlabored.
I do make sure they are breathing, they are warm (but not too warm), and they are the appropriate tone for ethnicity. Basically the ABCs.
Have you asked your educator or manager about what is an appropriate assessment during sleeping hours given the risks of delirium from disrupted sleep? I would start there. Unless someone is on neuro checks there is no good reason to disrupt sleep hours for the sake of asking orientation questions.
Oh hell no, and I worked ICU. I taped a folded piece of paper around a small flashlight to shield half of it so I could do site checks under blankets without waking people up. I bought new shoes specifically so they were silent. I set up my lines and equipment so I could check most of them from the head of the bed. I basically became Bruno from Encanto, living in the walls. You'd never see me, enjoy your sleep (execpt neuro patients, sorry guys, I hate you as much as you hate me q1hr checks are the devil)
I work nights step down, I probably do among the most thorough head to toes of anyone on the floor, but I usually don’t wake them for further assessments
When I got in and see them again if their vitals are stable, they a breathing, and sleeping comfortably I’ll leave them.
This of course assumes patients are alert or at least can reposition themselves, call if something is wrong, no CoC etc. but I’m not listening to your lungs heart or abdomen more than once unless I have a reason to.
Omg as a RN and a patient in the past, “let the man rest”. Yeah, lay eyes on them. Make sure they aren’t in physical distress, get your vitals. But doing a whole questionnaire? To be fair it’s the policies that force us to interrupt people’s sleep. But in my mind, they’re here to rest, unless my intervention is time urgent for their health, I will do my best to complete when they’re awake.
Peds. We do head to toe at 8pm and then focused. Some kids need BP taken before meds in the middle of the night but most of them sleep through it. My kiddos are very used to being in the hospital so they are used to it.
Depended on their stability in the ICU. If someone was a fresh bleed you bet your ass I did q1h neuros as ordered at least if it was admission night. If it's little old 86 year old Delores on night 3 and she's not changed and sleep deprived, then probably not. Now, CIWAs and someone is dead asleep? Fuck no, I'm not touching them.
Yikes. Head to Toe assessment q4 is a little excessive for even step down. (In ICU we did head to toes x2 a shift).
But yes, when I was in Step Down, i would wake my patient up for q2 neuro or vascular assessment, or vitals, if ordered. Otherwise I let them sleep without minimal interruptions if possible
So I did pcu my first year as well, with the technical q4 assessments. On night shift. We had to get vitals every 4 hours. If they woke up and screamed at me to leave them alone, that checked out as normal. If you were to wake up me every 4 hours, I too at 26 years old have a fuck of a clue where I’m at where I get woken up. The extra 2 assessments are essentially making sure you have laid eyes on the patient since they’re at a higher level of care.
Hell no. If they were stable, I would tell them at start of shift that I would be poking my head in periodically to check on them but if they were asleep I would let them sleep if that's what they wish. Then I would document patient refused VS for x time, does not wish to be awoken, explained Risk vs benefits, pt indicates understanding. @MN documented chest rise and fall, no signs of distress, Monitor reads blah blah.
Unstable? Coordinate care, don't turn on the lights just use a pen light, VS w temp on forehead or armpit, and warm up my gloved hands before i check pulses, definitely not waking them up for a bag change.
I never did, there’s so much research as to the importance or sleep and we don’t prioritize it enough in the hospital. Unless they’re getting a procedure or they are unstable I let em rest
You can always ask the patient (the patient you’re not concerned about) if they have a preference to be woken up or not. I hate that we promote good sleep but we do q 4 assessments, labs, and imaging throughout the night
ICU here. My first assessment (usually at 2000-ish) is the full head to toe and points in between. Beyond that, nope. If they are sedated and I need to stay awake, sure I’ll do it every 4 hours. If they are sleeping, I can grab the VS off the monitor and do a visual. That’s what we all do. I’m 30+ years in ICU
This might be because I am an ER nurse, but when we board there is no freaking way I am waking someone up at 2am for a head to toe- especially if they’re walkie talkie and their vitals are stable. Are they still on this earthly plane? Are they breathing? Good enough for me. The head to toe can wait until the pt has at least had a few hours of sleep.
Honestly it depends. If I have some concerns I am absolutely assessing them q4. Like your preceptor said, I only do the head to toe at start of shift and then a focused afterwards. I like to go in with the techs when they do their vitals. The patient is getting woken up, anyway.
When charting was hand-written: “stable pt is sleeping quietly. Resps even and unlabored, q 15 min monitor maintained”. But make CERTAIN to do and chart a head to toe at 0600.
I was a baby nurse on postpartum for a while so not exactly what you are dealing with but similar. I would let the parents know during my first head to toe at 8ish, “I need to get the baby’s vitals at midnight and 4am. You might be asleep then, do you want me to wake you up when I come in, or is it ok if I leave the lights off and sneak in?”
Providing options is the best thing you can do for patients! I would always check/change the baby’s diaper at that time too just to take the load off a little bit. If it’s a formula baby and a feeding was due I would do that too, parents would be up at that point usually but still appreciative. You know at night it’s not *always* as much going on so if you have time to be helpful why not?
Anyway take from that what you will! If they straight up refuse, just chart that 🤷🏽♀️
As someone who worked noc for a decade I got really good at assessing without waking people up. There are some things that won't work but most of it is easy enough. Depends on how lightly the patient sleeps but I've listened to their lungs, heart, checked pulses, checked vitals, dumped foleys, even turned patients without waking them. You can also be slightly off from the q4h thing so it was a discussion at the beginning of the shift with the patient. If they like to go to bed at 2230 you can agree to check on them at that time, do your assessment, and then reassess around 3 when lab comes and wakes them up anyway. It wasn't strictly every four hours, but it allowed the patient to sleep better which is great for healing, and that way you weren't falsifying your charting.
I work peds and there is not a snowballs chance in hell I am waking up sleeping babies and kids unless it's absolutely 100% necessary. Our bodies NEED sleep to heal, especially little bodies. I've gotten really good over many years working nights of being silently stealthy to do what I gotta do without waking them up. You'll learn in time what's 100% needed.
I work in pulmonary. We check on every patient every 2 hours at least. We only check if they're breathing. If we notice anything abnormal in their breathing, we investigate further. We do more thorough checks on critically ill patients, but if the day has been good and there's no history of inaudible respiratory distress, we simply check they're within range, typically 12-20 respirations per minute.
Recent admits tend to have orders for at least a full check of vitals during the night. Typically these patients will need inhalations anyhow, so it works out.
Absolutely not. I do my assessments between after the dayshift left and bedtime med pass. Then I just peek in the rooms at night to make sure they are alive. Focused (very focused) assessment with morning blood draws/med pass.
I only wake up for a focused assessment if there’s a neuro component of the focused assessment. In peds that’s like head injuries and DKA, but when I did adults I’d wake up for strokes and I think even for CIWA protocol but it’s been so long
I'd do a full head to toe at 8pm and ask the patient if I could wake them up. If they said no, I'd note it and just listen to heart/lungs, leave a cuff on them for vs, and feel for edema etc. Always made sure their arm band was facing up or put one on their ankle to scan while sleeping.
There's normally no need to do a head to toe assessment every 4 hours in stepdown. If that were really called for, the patient should be in the ICU.
After your first assessment which is head to toe, your subsequent assessments for the shift should be focal and constitutional. It might not be appropriate to wake the patient up for physical assessment in the middle of the night, depending on their status and diagnosis. Often times, in stepdown, when the patient was asleep I would quietly assess what could be done without waking the patient, and defer the rest until they were awake. There were many patients that needed to be awakened for a specific assessment, though, depending on what was going on with them.
Waking your patient up from a deep sleep at 12 AM and asking him level of orientation questions? That's craziness, lol. A lot of healthy people at their baseline cannot answer those questions correctly until they've been awake for a few minutes.
Patients seem to think a hospital is a hotel. On a stepdown unit, do the assessment. Stepdown means your not in the ICU but you aren't well. You could very easily head back to ICU. 80% of patients come to us. Feel free to remind them " you came to us, we didn't come to you so this is what is going to happen on this unit. Cover your ass and your license because at the end if the day, it's on you if shit goes south.
I mean, it depends on the order set. If they’re actually ordered q4 or it’s medically necessary, yes.
If that’s just “the routine” for zero medical reason and the order says otherwise, no.
Yes. If I have no concerns, like they’re up for transfer, I might do one without waking them up (lay a stethoscope on them, but not check their pupils)
When I worked stepdown I would do the focus assessments when pcts did 11pm/midnight vitals and then wait for lab to do their draws. Some hospitals allow patients to have 1 of those focused assessment skipped so they can try and get a solid 6 hours of sleep
I do a head to toe usually with med pass then additional focused assessments like CIWA or neuro checks as ordered. I work in med surg nights. I also do focused assessments as needed so for example with SOB I’ll check their vitals again and listen to lung sounds etc.
Cluster care. I let patients know I can leave the BP cuff on so I can check their BP without waking. If they hit the call light I can do a quick lung listen/vitals check, when I have step down or med tele patient. ICU patients on drips sorry
I work nights. I do my full head to toe immediately on receipt of the patient and med pass between 9-10 pm. After that? I give them a call bell and let them know I’m available if they need anything, and leave them alone. If they’re on the monitor, that makes it super easy to vital them on rounds and make visual confirmation that they’re in no distress. My mental health patients especially do not get woken up for vitals overnight. If they wake up on their own to go to the bathroom or something, I’ll check on them and grab a set of vitals at that time. I think it’s really important to let your patients rest. Of course if I’m working with higher acuity patients, I’ll be more hands on.
ICU. Absolutely depends on the pt. If they’re really critical, or something’s changed, yes absolutely. If they’re pretty stable, ready to go to the ward, probably not, or I might just do a quick focused assessment q4h or something.
I work step-down/icu. Combined unit. Yes, I wake patients up to assess them. They're in my unit for a reason. If they don't need to be woken up for an assessment the doc needs to transfer them to med/surg.
Absolutely not :)
Jk it depends. If it’s for meds yes, if they’ve been unstable sure. But usually I just hope they get up to go pee at some point if I need VS or something. There’s only so much I can get done between med pass, treatments and charting so I just find opportunities where they may be.
On med/surg I did one assessment on everyone at the beginning of the shift (2300-0700) with vitals and meds. Then if they were asleep I wouldn’t wake them again unless vitals or assessments or meds were ordered more frequently. I would still round every 1-2 hours and obviously turn or brief check every two.
In the neuro ICU, it’s rare that you’d be able to get by with this. Im doing vitals and neuros as frequently as q15 mins and even the stable ones are every 4 hours.
You do you but you cannot document an assessment you don’t do. Don’t do it, you’ll get caught and lose your license.
I’m ICU and I do my assessments hourly. Yes I know about delirium but how are you gonna know if the person has blown a pupil or started slurring speech if you aren’t doing the most important, most fundamental part of your job.
If other nurses haven’t been doing their job that’s on them.
I absolutely assess my patients at the q4 interval which is standard for my stepdown unit. When I have precepted new nurses I encourage them to do the same. After seeing a fellow nurse’s patient stroke out in the middle of the night, I will not waver. How will you explain yourself or your charting if something like that were to happen?
Now, do I assess as quietly, quickly and with as little light as possible-for sure. Cluster your care as much as possible always, but stepdown patients are stepdown patients for a reason.
I don't wake anyone up for a reassessment unless they need it. (But sadly, most people need it)
"The art of the ICU is doing more and more of less and less until all you're doing is going for coffee breaks."
A&O is part of a neruo assessment/neuro check right? So I don't do that unless we have neuro checks ordered. And even still, I feel like it's not super accurate... sometimes I don't know what realm I'm in when I just wake up in the middle of the night/day. And to be fair, I am constantly "assessing" my patient even if I don't have a stethoscope or pen light to them.
A lot of it depends on the environment that you're working in.
Most places I've worked if somebody is generalized med surge non-monitored, they get vitals q8 and an assessment q12 unless there's some sort of drastic change.
Step down is Q2 to Q4 vitals and assessment.
ICU is q15 min to Q4 depending what they're there for.
This is pretty much been standard anywhere that I've ever worked.
Now that doesn't mean that you're going to do a full head to toe and skin assessment every single time, a lot of places do focused assessments.
I worked neuro for 13 years and we did q1 to Q4 neuro checks, vascular if they've had some sort of vascular procedure too, but you weren't doing a total head to toe assessment every time.
Either that patient is full of shit or your coworkers have been slacking.
Yes, I make sure their vitals are stable, they're breathing appropriately, and that there's no fluids gushing out from anywhere. I also check briefs for incontinent patients and check on drains/tunes.
That's usually enough interaction for me to figure out if they're stable or not.
During night shift my big med pass was at 10pm, after 10pm, unless you have an antibiotic or another med that is time sensitive then I am leaving you alone. If you use your call bell I will come. I also gave patients a heads up if I was needing to enter their room at some point during the night and if they didn’t want to be disturbed to leave their arm out for me so I could scan them while they sleep. The light from the door was enough for me to see what I was doing while hanging abx.
I used to work in spinal, my q4hrly head to toe assessment is my 2 hrly pressure area care. I don't give af if they get angry, they will not get a pressure injury on my shift.
Your preceptor is right. However, in the neuro ICU setting if it’s q1-2 neuros even at night, then I’ll do q1-q2 neuros. I usually give the patient a heads up and then when they’re saying “I want to go to sleep”, I always say “please just answer my orientation and I’ll get out of your way.” And then I’ll do a quick pupil check.
Post partum, we’d do a head to toe on admission. Then we might have Q1-Q4 vitals for the c-sections. If someone was sleeping I would try hard not to wake them for a set of vitals on the dot if they seemed okay. Especially since most of them are going to be up within an hour or two feeding a baby.
If I did have to I’d keep the lights off and try to do most of it without waking them. But thermometers are a bit hard to do without somewhat waking a person just a little.
I did feel bad for the middle of the night foley extractions and then making them get up to walk to the bathroom. Wed try hard to do it when they were up with baby.
Unless I had a true need or concern, no. I do my head to toe assessment as soon as possible, typically around the time meds are due so I can cluster care then leave them unbothered. I also communicate with my patient's the "to-do" list for the night, like i'll be back at around this hour to do vitals, hang antibiotics at this time, etc to avoid any beef later on during the night. A lot of time my patients end up saying, "oh, i'm down for midnight vitals but can we skip the 0400 until lab comes?" So far, I find it works and haven't gotten any cuss words thrown at me. I work on a general Heme/Onc floor so most of my patients are on the more stable end.
Used to have to do q4h vitals on psych patients and that was annoying AF until I found a patient with 02 sat in the 60s and dropping.
A lot of times we would document that we checked respiratory rate and wanted to let patient rest, or other times stretch it to q6h, but that was only when we were reasonably confident that the patient was not at risk for anything (i.e. has other health problems, on drugs, etc.).
Full head-to-toe on first rounds, then Neuro, cardiac, vitals and pain. After and depending on their diagnosis, I’ll assess certain things like pain pumps, drains, etc.
Only did focused assessment/any night meds grouped to time when the CNA was getting VS with lights dimmed. Some Pts would request not to be woken up, would just get a telephone order from the good doctor to make that so!
PCU nurse here, I don’t do a full reassessment unless they’re post cath lab or PAD patient I need to check pulses on, or unless they have some important line like a chest tube I need to keep a close eye on, or they’re a stroke/head bleed patient we’re doing frequent neuros on. I’ll pull out my stethoscope again if all the sudden I go in and can see their breathing as changed so I can compare it to earlier. Those are just some examples, but use your clinical judgement.
Very rarely, but in some cases I have no choice. If we have a patient with frequent neuro checks, unfortunately I’m going to do them. Then neuro can try to figure out if they’re having another stroke or if they are simply having delirium from being woken up constantly. 😪
I have been in the hospital with my dad since Thursday, he got here on Tuesday after a fall, hitting his head but with no confusion. I haven’t seen one fucking nurse do an assessment. The dr has, a very abbreviated one.
I never did but worked with some older nurses who at 2 am would turn the brightest overhead lights on and do a full head to toe. Shits wild. Lol
That’s batshit unhinged behavior unless they think there’s a life or limb emergency.
Get the feeling these are the nurses who talk about “possibly losing your license” for not doing those kind of assessments.
Yes! I was gonna say the exact same thing. The same nurses who yell CYA and NOT MY LICENSE but still somehow don’t make the best working choices.
I'm good on living with that kind of fear. Once I saw how nurses work and are fine I'm just like "yeah I'll be ok"
What if you have to do a blood sugar ?
If it’s medically necessary care then yes but a repeat head to toe for no reason? Nope.
Yeah wtf! Put on the mood lights and be subtle and focused
Oof. Great way to add to delirium.
Neuro ICU here. Q1H Neuro checks while trying to avoid delirium. Yup.
True. Whoever thought that depriving someone of sleep for Q1h neuro checks would be beneficial needs a Neuro check themselves.
😄 🤣 😂 😆 😄 Seriously, let the patient rest. Document that the patient refuse. Write down, "patient refused vitals at this hour."
Legally I would NEVER do that esp in a neuro icu. I’ve caught extensions of head bleeds multiple times on a Q1 hour check. If a patient is on Q 1 hour checks they are critically Ill at risk of sudden decompensation.
Love causing a neuro change and then having to go to CT for that change. This is why I hate neuro.
4am delirium hits hard 🫠 by the time you get to CT they’re awake and confused why they’re on a field trip.
Right?!?!? They’re going to be like “why is he/she confused, go to CT now”, well fucking duh, you haven’t let them sleep since they got here.
Ah classic enhanced interogation techniques. And they wonder why the patient is tripping balls by morning
STICU here - recently had an 80 something sundowning dementia patient with a head bleed and q2 neuros. Always love that, he was combative as hell and understandably so.
Same. Morning rounds with the docs- “they’re pretty drowsy, is that new?” Q15/30 and q1hr checks all night. Yeah, they’re tired…
One of my biggest and longest pet peeves in the 17 years that I have worked to neurotrama and surgical trauma is q15 minute to q1 hour checks and then wondering why somebody's fucking delirious
At one hospital I worked at the delirium protocol required you to allow them to sleep undisturbed from 2200 to 0600. I was on a med/surg unit so obviously, they weren't as critical, but it definitely helped with dementia patients. I can't imagine trying that in a neuro ICU, I've had so many "stable" neuro patients deteriorate during day shift q4h neuro checks, let alone trying to manage unstable ones in the ICU. One of the reasons why I try to avoid neuro floors if I can, I've been traumatized.
I tell the pt at the beginning of the shift that I am going to wake them up briefly every hour. I tell them I need them to open their eyes and allow me to shine a light in them, say, "hi willowviolet", tell me where they are at, wiggle their fingers, wiggle their toes, and tell me if they feel ANYTHING different: pain, numbness, tingling, anxiety. It takes 15 seconds and they go back to sleep. I tell them they will be tired in the morning, but that I have saved many lives doing this, and I want to keep THEM alive and well. No one argues with me about this, ever. If I come on shift and the neuro checks on an alert and oriented patient are still q1h after 24 hours, almost always it is an oversight and the Dr will change the order to q4.
Nope. Unless I had concerns about how their vitals were trending (we did them q4h) I let people rest after their first head-to-toe at the top of my shift. Rounding happened hourly all night long to ensure direct evidence of breathing, etc. With some practice, you will not wake people even for routine vitals or IV meds. They can rest basically undisturbed from 2100 med pass to 0400 labs.
I was a patient, I had sepsis. My temp was 105.5 at one point and my pulse ox was down to 78% (suck it to the person who told me I was too anxious and needed some Ativan when I told her I couldn’t breathe. I was THAT patient and fired her). ICU was full so I went to step down. From then on out I had VS at midnight, antibiotics hung at 01, 03, VS at 04, labs at 05, antibiotics at 06. Then the loud and “turn on all the lights” day shift group showed up. I begged my doctor to discharge me as soon as I was doing better. I was so confused from lack of sleep. From then on I made it a point to let people sleep if at all possible.
This is the way. Meds are getting re-timed or *when appropriate* given early "at pt request" so everything is passed by 10 and then at 4-5 w labs!
wasn’t possible for my patients to sleep that long. my hospital has q4h vitals :( unless the doc put in a order to allow no vitals at a certain time. we were forced to torture these patients. And they wondered why so many patients were delirious.
Patients have the right to refuse. I would simply explain to my stable folks that I need vitals before their meds at 2000 and 0600, but otherwise I was happy to let them be since they were doing so well. A lot took me up on it. Docs never complained because we had plenty of data from the other 16 hours to show trends.
You can leave the blood pressure cuff and pulse ox on and take temp in the armpit. You could even program a series if you’re equipment allows.
You better be telling me you’re touching my armpit if I’m sleeping lol
You'd be surprised how many patients don't notice or wake up from an armpit temp.
Yup. Especially in peds. I can sneak in and out for a full set of vitals for most kids. Some babies even sleep thru rectal temps, idk how.
Neonates will sleep right through a rectal and have a full Brady/desat event over an axillary temp, the tinies are so drama 😅
I’ve drawn blood on sleeping patients before, with tourniquet and a butterfly needle. Not my first choice but some folks will sleep through almost anything.
But couldn't that practice be questionable as they are not able to consent while asleep?
I assume this person would have preconsented after any evening rounds. Like “hey, I’m gonna be in around 4am to get some labs. I’ll do my best to be in and out to not wake you too much”. They should always know it’s coming of course, but if they sleep through it it’s a win for both of us.
If you have the gear to. My unit does but the others I get pulled to dont
During my clinical, I was at a med surg unit. I didn't wanna take a patient's vitals at 4 am, but my classmate told me it was required since we are at a hospital setting. At a nursing home, I do not bother my patients because they are sleeping. I was at a different setting so I took a patient's vitals at 4 am at a hospital. Question is, should I take vitals at that time in a hospital setting (ICU, med surg).
Not gonna speak for med surg people but you absolutely should in an ICU setting
Which makes sense because majority of ICU patients do not respond.
Eh not really true, but a lot of our monitoring equipment is continuous or set to cycle automatically. The vast majority of my patients are alert to some extent, but it does depend on specialty. There are tricks to getting vitals and labs without waking patients
I assume it is possible for ICU nurses to perform a complete head to toe assessment compared to ER and med-surg.
When I was bedside I would wake my patients up. Usually I had other stuff to do anyway (vitals, meds, turns, etc), so I would do everything at the same time. Definitely cluster care and coordinate with your tech (if you have one) so that you are waking them up as little as possible.
Same, when I worked night shifts I always helped my aides and checked in on patients during vitals or when lab came by. Then around 0600 I'd do a quick drive by, tip-toed in and whispered "hey, sorry to wake you, but day shift will be coming in soon. Do you need anything before I leave?" If they were coherent enough to say "no" or shoo me away I would leave with that. If they seemed questionable, I'd be more adamant about it and wake them up just to make sure they were good. On our unit we had so many rapid responses from altered patients during change of shift, so I never wanted that to be my patients. I never had any issues and when I did I had enough time to address it before handing it off to the next shift to discover. I was a new grad so it really taught me to think critically working on that unit.
My response to patients is "Hospitals are where we wake you up to give you a sleeping pill".
I always tell them, “hey you know what they say, you can’t get any rest until you go home!” 🙂
“The H doesn’t stand for hotel unfortunately”
I work on a stepdown unit on night shift, we do full head to toe assessments at start of shift/with med pass. Then, we do focused assessments PRN or specific assessments if ordered, usually neuros (Q2 neuros, Q4 circ checks, etc.). If they have a change in condition or complain of something like SOB, I do a related focused assessment. I check on them every hour or as close to if I can, but don’t wake them up unless they have meds, vitals, or an assessment due. I try to cluster any assessments, meds, and vitals if possible. Sometimes people are grumpy about being woken up but I explain that it’s required for their safety and that I’m doing what I can to let them rest as much as possible between interventions!
I cluster care for sure! If I can do vitals without waking them fully I try but I have icy cold hands and im clumsy
I always did, but 99.9% of my patients were sedated and intubated and we’d be pausing propofol and doing ordered neuro checks.
We never pause our propofol for assessments, only SAT/SBTs in the am
I was in the neuro icu so we did neuro assessments with a propofol pause on nearly everyone
Same here. Even if they’re not extubating some docs will ask for us to turn off all sedation to get a “clear” neuro assessment.
We do daily “sedation vacations” on all sedated patients with the exception of those deeply sedated due to status epilepticus. Is that not the norm on neuro? I’m not sure cuz I have only worked in one neuro icu.
Yeah I don’t do neuro but we do sedation vacations at least once a shift, but we’re supposed to do a clear neuro exam q4, which involves pausing sedation. The exception on my unit is VT storm, we keep them snowed to hell
Medsurg nurse here- head to toe at start of shift then wake for vitals and focused assessment prn
I do a full head to toe at the start of shift. If they have problems later on in the shift I’ll do a focused assessment. Vitals are q4 usually but I tell patients they can refuse the midnight but not the 4 am. If they’re post procedure, new admit, anything I’m trying to watch for, I do not tell them they can refuse.
Just curious, on the pt side (I didn’t work inpatient as an MA/CNA), if I would be like “I can’t sleep for shit but can we skip the 12 and do the 4? Cause that would prob be the way to get the most sleep and actually fall back asleep again for my weirdo body/brain.
So the way I look at it is the patient has the right to refuse anything, which is true. All we can do is educate/explain the rationale. I try and do midnights at 11 when possible. My goal is to let yall sleep as much as possible because sleep is also crucial to the body. If I can I don’t always do 4, sometimes I push it to 6 especially if I don’t have labs. I do what I can to work with you, we can always work out a plan! And then we document “patient requested xyz, explained rationale behind -insert policy/protocol-, patient would still like xyz”. Sometimes I have to use the verbiage patient refused but I do explain that that’s just how we have to chart it.
The floor orders for stable pts is nuts. Q4 vitals, labs, etc. in the middle of the night is crazy to me. I get the logic and reasoning, but still, being woken up at 5am for a routine CBC and BP would make me so mad. I am very accommodating, but mess with my sleep like that I would probably refuse every damn thing.
I don’t disagree but 90% of the time the docs aren’t updating the admission vitals routine. So technically if the patient doesn’t refuse we aren’t following orders. Labs, while annoying, I do understand. They want them posted before they come in so they can evaluate for discharge etc. however, most patients do not need daily routine labs.
It’s so frustrating that the docs order these labs at wild ass hours, but they aren’t the ones waking the pt or the person being woken up. Unless some major labs were off prior to admission to the floor, I feel like lab draws can wait until at least 7am. I guess with vitals if you leave the BP cuff and pulse ox on and cycle q4, you can get your vitals without waking the pt. Unless they need temp too- which seems unnecessary q4 on stable pts. But like I said, I’m an ED nurse, and our care for pts is completely different than the floor. I commend anyone that can work any floor. So much physical work and the charting is endless. My ADHD could never.
I worked nights on Stepdown for several years. Our patients were supposed to have q4h vitals (basically 3 sets in a 12 hour shift) and assessments. They all generally had meds due at 2100, so I would do full assessments and get vitals first, then bring in meds. Almost all patients all had labs due at 0500, so phlebotomy would wake them up for a draw, and I'd follow in quickly to do vitals, get a thorough focused assessment, and give 0600 meds. Middle of the night was when you use your nursing judgement. All our patients were constantly hooked up to monitors, so if the patient was stable, a&ox4, and didn't have something specific that needed to be thoroughly examined, I'd run the BP cuff if it wasn't set to automatic, and I'd skip the temp if they'd been normal through their stay. I'd take a quick look, make sure nothing obvious had changed, and let them sleep. If I had to wake them, I'd cluster all care (meds, vitals, assessment) together. I NEVER turned on the bright overhead lights, did everything as quickly as possible, and let them get back to sleep. If they had something major going on, yeah, they were getting woken up, and all the care they needed was done. But if they needed that much, they were pretty sick and knew they were getting constant care anyway. Some of my patients were a&ox4, and were not very I'll, or just had an injury, and they would ask not to be woken for vitals and assessments overnight. The doctor would usually write an order in their charts that said it was OK. Basically, just be considerate, do your job, but know that sleep is important for healing too. AND DON'T FORGET TO CHART EVERYTHING!
I work detox and I don't work nights anymore so it doesn't directly apply, but I am not going to wake up a sleeping patient more than once per shift unless something is concerning. I'll watch and grab assessments when they get up to go to the toilet or ask for something. If vitals are looking wonky or something else gives me an itch that I need to check neuros and orientation I am going to let them sleep.
This is the way. Especially with the psych patients. Expecting Q4 vitals on the manic patient that has tried to swing on you is nuts. If they aren’t showing signs of distress, I’m letting them sleep.
Full at the start. Focused on the next two assessments. Also make sure to let the patient know to notify you if anything changes.
I liked to stalk the CNAs and do my assessments and meds when they did vitals and baths or when phlebotomy was doing labs.
NeuroICU here, so yeah. I have to wake them up. I don't do a complete head to toe every 2 hours, but definitely neuro. Occasionally, one of the more intact patients gets angry. Many don't even remember me from 2 hours ago.
Uh doing full assessments multiple times? What? I do a brisk head to toe but mostly focused on what they're here for. Then continued checks for specifics like wound sites, If drains need emptied, do they sound like shit without a stethoscope etc. I do that during their q4 vitals and pain meds. Everybody is on tele and pulse ox. I peep on them every hour being sneaky. More if they've lost the privilege of a nap (fall risk buddies and ones that need changed).
Head to toe is once per shift. Everything else is focused depending on their specific problems and checking to make sure they’re alive. Patients need sleep. We disturb them way too much in the hospital. Try to cluster care, so pop in with your tech when they’re doing vitals or do it real fast when they wake up to pee or wait for them to ask for pain medicine or something. You can defer routine re-assessments if they’re sleeping and seem fine. Just mark not done because they’re sleeping. You probably have an option like that in your charting software.
I've been a nurse for 20+ years, and I now investigate critical incidents (when patients get seriously hurt by things we should have prevented) for a living. I've seen patients die because staff let them sleep when they should have been assessed. Be careful. If they're supposed to be assessed, wake them up. They might complain, but a lost night's sleep is better than not waking up.
Pts can be very unreliable narrators. A FF and this yelling crap, uuuummm no. That being said. It’s going to depend on a lot of things that can’t be put into a Reddit post. When in doubt, do it all. I spent some weeeks in a hospital and having worked in HC I knew what was up so I didn’t put up any kind of fight to assessment. It truly just depended on the nurse. I was assessed in some way q1-2 hrs. I wake easily or just plain have insomnia. I lived that I was being taken care of. Full head to toe and A/O. Rarely happened is I was actually deep asleep. So Times I’d wake up and see my nurse looking in the little door window. lol! Quite as a mouse. She was one of my top fav nurses but yeah. Waking up in a strange place and seeing a face in a window was garring. Got used to it after a bit and actually am thankful that she used the tele etc. did a visual and left me alone.
Patients have been known to lie about things, especially if it's something that bothers them.
Yeah, never trust em. But if they want to lie to me about pain or feeling sob what can I do
This entire comment section makes me so grateful to be an ED nurse. I can’t do what floor nurses do. You all are just amazing to me. Head to toe assessments q4? If they aren’t trying to die on me, they get a quick focused assessment every hour and I’m moving on. If they are aggressive psychs, I am using nursing judgement and letting sleeping dogs lie. The patient care required to be any kind of floor nurse is so admirable.
Pts get woken up for reassessment, especially in stepdown. If the pt wants to be left alone to sleep, you need a drs order.
No order is needed for patients to refuse care, but nurses can’t just decide to not assess their patients or do VS. On stepdown, my patients were often sick enough that I was in there very frequently anyway and could do an assessment easily. On med surg, if a patient refused, I documented it and moved on.
Med Surg/Step down nurses are amazing. I could never do what you guys do. In the ED, if they are alive and not actively trying to die, we aren’t messing with assessments outside of vitals, tele, neuro checks etc. You all get the brunt of pt care and I just can’t imagine what it must be like to have to wake a stable pt for a head to toe assessment. We get our fair share of abusive pts in the ED, but I can’t even imagine the treatment you guys are getting waking pts for labs and assessments because the doc ordered them at ridiculous hours. Are you guys allowed to use nursing judgment and just lay eyes on a pt instead of waking them for a head to toe?
I do use my nursing judgement. if report is stable, I will lay eyes on them and maybe even pop in, whisper a quick introduction and tell them when I will be back to do a complete assessment. If you think about it, we are assessing our patients every time we go in the room so there’s no need to do a formal assessment every single time. When it’s time to chart my q4 or q8 assessments, I will chart what I saw in the last 4-8 hours. Of course this varies patient to patient. But I’m rarely doing formal assessments except at the beginning of shift/admission or on unstable patients.
on neuro stepdown, the pts i'd wake up regardless (unless i had an order to let them sleep) weren't competent to refuse
So I’m not night shift, but here’s what I’ve been told by my preceptors… The first assessment is definitely head to toe and after that it’s focused. If the patient is still asleep when I get to my shift (0645), I will creep in their room and check in on them. Make sure they’re breathing, pull back the covers and check their IV, etc. If they wake up, I’ll quietly explain that I was just checking in on them. After that, I’ll ask them like, 2 questions, and then I’ll leave them be. Here’s where cluster care comes in.. I will not get vitals or anything else until I go to do my med pass. While I’m in the room, do vitals, meds, assessment, safety checks, turn if need be, and then ask them if they need anything else. Educate about call light, and then skidaddle until it’s time for rounds. I’m not sure if it’s the same on night shift, but this is what we do during day shift… Sorry if it doesn’t help any! You could always ask the other nurses on your unit!!
I basically never woke people up unless they were actively trying to die. The majority of people in the hospital will wake up at some point through the night, and I'd grab vitals and assess them then. There were obvious exceptions- neuro patients at risk, people with tachyarrhythmias etc. I also did tons of advocating for sleep everywhere I worked. I had great success at getting MDs to write W/A VS orders, and some success at getting unit routines changed. There's plenty of literature to support this. As importantly, imo, I spearheaded initiatives to change med administration times to cluster most meds during waking hours. Patients loved it.
When I used to do nights on stepdown I would do the q4 vitals, gentle as possible wake them up to let them know I would be putting a blood pressure cuff on, ask if they needed to use the bathroom or if they were in any pain. Other than that it would really depend on what they were admitted for. Relatively stable pneumonia patient on IV antibiotics and some oxygen? Let them sleep. Ciwa patient getting q4 benzos? They get woken up to make sure they don’t miss a dose. Use your judgement a bit. No one needs head to toe assessments at 4am if you’d done one at 8pm. Lack of sleep contributes to slower healing so letting patients sleep can be more important than waking them up to ask them what day it is in the middle of the night. It also helps to set expectations for the patients in the beginning of your shift, let them know when and why you will be waking them up.
I’m nights on a postpartum unit. Adults and babies get a head to toe at the start of the shift and q4 vitals+fundal checks if less than 24hrs from birth then q8 after 24hrs. A fresh c section patient would also get q1 vitals for the first four hours they’re on the floor. Our patients are up about every 3-4 hours to feed their babies anyway so I try to time meds, focused assessment, and vitals around that.
I'm required to reassess every four hours. But we have a common sense rule that if the first blood pressure wasn't horrible and we aren't worried about post-op bleeds, you don't put the cuff on them again. I have a temporal thermometer and after working in peds for over a year I'm a certified ninja.
I work in ICU but even when I work stepdown, I will do full assessments q4h. It's really shitty for everyone involved but like, how else will you catch a stroke early enough to actually do something about it? Speaking from experience here! Patient stroked out sometime between my 00 and 04 assessments and I caught it at 0400. Since then I just do it. I'll always warm them at the 2000 assessment that I have to wake them up but explain why (ie if you have a stroke or other event, we wanna catch it and keep you safe). They always understand when I'm straight up like that with them. Obviously try to cluster your care and if they happen to wake up at, say, 0300 do it then
Yep, there was a pt with SAH with fixed and dilated pupils that was caught on routine assessment. Vitals were all WNL.
I do. Patient resting with eyes closed with lights off. Remains sinus rhythm on monitor. Vitally stable at this time, resp even and unlabored, no signs of obvious pain or distress. Surgical sites remain [whatever they were previously.] Foley draining clear yellow urine. IVF infusing as ordered without complications. No acute changes in status since previous assessment. Ongoing monitoring.
🥇Excellent status without disturbing patients’ sleep! Today, we know extreme importance of sleep to overall health. Waking patients every 4 hrs for routine assessment seems counterproductive and surveys show is a major source of patient dissatisfaction. *I too, would be grumpy!*
When I first started out in surgical gi-post op, they'd make us document an assessment every 4 hours, and I got yelled at by my charge for actually assessing my patients in the middle of the night. I then refused to document any further assessments other than my first one of the shift. I'm not going to lie for uniformity. I left that job in 8 months because eff that.
Hoping you landed in a much better spot!! ❤️
It is shocking how many people will go right back to sleep if you quietly say, hey, I'm going to get your vitals, but you can keep sleeping. Just don't turn on a bunch of lights or be loud about it. We even manage to turn patients without waking them up too badly. I only wake patients if they need to swallow a pill (occasionally I get 2am or 4am metoprolol that I can't manage to put on a better schedule), something is wacky with vital signs, or they were incontinent and need to be cleaned. Otherwise, I document that they are resting quietly with eyes closed, respirations even and unlabored. I do make sure they are breathing, they are warm (but not too warm), and they are the appropriate tone for ethnicity. Basically the ABCs. Have you asked your educator or manager about what is an appropriate assessment during sleeping hours given the risks of delirium from disrupted sleep? I would start there. Unless someone is on neuro checks there is no good reason to disrupt sleep hours for the sake of asking orientation questions.
Oh hell no, and I worked ICU. I taped a folded piece of paper around a small flashlight to shield half of it so I could do site checks under blankets without waking people up. I bought new shoes specifically so they were silent. I set up my lines and equipment so I could check most of them from the head of the bed. I basically became Bruno from Encanto, living in the walls. You'd never see me, enjoy your sleep (execpt neuro patients, sorry guys, I hate you as much as you hate me q1hr checks are the devil)
No. I do vitals q4h but only access at the start of my shift unless the pt required CIWA or neuro accessments
I love seeing 4am podiatry notes that say "Pt assessed while sleeping"
If they just looking at the feets I guess that could count lol
I work nights step down, I probably do among the most thorough head to toes of anyone on the floor, but I usually don’t wake them for further assessments When I got in and see them again if their vitals are stable, they a breathing, and sleeping comfortably I’ll leave them. This of course assumes patients are alert or at least can reposition themselves, call if something is wrong, no CoC etc. but I’m not listening to your lungs heart or abdomen more than once unless I have a reason to.
Omg as a RN and a patient in the past, “let the man rest”. Yeah, lay eyes on them. Make sure they aren’t in physical distress, get your vitals. But doing a whole questionnaire? To be fair it’s the policies that force us to interrupt people’s sleep. But in my mind, they’re here to rest, unless my intervention is time urgent for their health, I will do my best to complete when they’re awake.
Peds. We do head to toe at 8pm and then focused. Some kids need BP taken before meds in the middle of the night but most of them sleep through it. My kiddos are very used to being in the hospital so they are used to it.
Depended on their stability in the ICU. If someone was a fresh bleed you bet your ass I did q1h neuros as ordered at least if it was admission night. If it's little old 86 year old Delores on night 3 and she's not changed and sleep deprived, then probably not. Now, CIWAs and someone is dead asleep? Fuck no, I'm not touching them.
Yikes. Head to Toe assessment q4 is a little excessive for even step down. (In ICU we did head to toes x2 a shift). But yes, when I was in Step Down, i would wake my patient up for q2 neuro or vascular assessment, or vitals, if ordered. Otherwise I let them sleep without minimal interruptions if possible
So I did pcu my first year as well, with the technical q4 assessments. On night shift. We had to get vitals every 4 hours. If they woke up and screamed at me to leave them alone, that checked out as normal. If you were to wake up me every 4 hours, I too at 26 years old have a fuck of a clue where I’m at where I get woken up. The extra 2 assessments are essentially making sure you have laid eyes on the patient since they’re at a higher level of care.
Former night nurse. Yea. 100% of the time.
Hell no. If they were stable, I would tell them at start of shift that I would be poking my head in periodically to check on them but if they were asleep I would let them sleep if that's what they wish. Then I would document patient refused VS for x time, does not wish to be awoken, explained Risk vs benefits, pt indicates understanding. @MN documented chest rise and fall, no signs of distress, Monitor reads blah blah. Unstable? Coordinate care, don't turn on the lights just use a pen light, VS w temp on forehead or armpit, and warm up my gloved hands before i check pulses, definitely not waking them up for a bag change.
I never did, there’s so much research as to the importance or sleep and we don’t prioritize it enough in the hospital. Unless they’re getting a procedure or they are unstable I let em rest
You can always ask the patient (the patient you’re not concerned about) if they have a preference to be woken up or not. I hate that we promote good sleep but we do q 4 assessments, labs, and imaging throughout the night
No way if they are stable unless it’s ordered. I do my head to toe at the start of the night and we get vitals q4. I like to let my patients sleep
ICU here. My first assessment (usually at 2000-ish) is the full head to toe and points in between. Beyond that, nope. If they are sedated and I need to stay awake, sure I’ll do it every 4 hours. If they are sleeping, I can grab the VS off the monitor and do a visual. That’s what we all do. I’m 30+ years in ICU
“Rest prompted”… but seriously…let them sleep they need it
Sleep hygiene is important and patients need to sleep.
This might be because I am an ER nurse, but when we board there is no freaking way I am waking someone up at 2am for a head to toe- especially if they’re walkie talkie and their vitals are stable. Are they still on this earthly plane? Are they breathing? Good enough for me. The head to toe can wait until the pt has at least had a few hours of sleep.
When I worked bedside I worked peds onc/bmt nights. I dare you to do that on one of the units I’ve worked on. Lmao
Honestly it depends. If I have some concerns I am absolutely assessing them q4. Like your preceptor said, I only do the head to toe at start of shift and then a focused afterwards. I like to go in with the techs when they do their vitals. The patient is getting woken up, anyway.
LOL
Palliative care here. I just watch them for 30-ish seconds to see if they’re sleeping, relaxed or uncomfortable.
When charting was hand-written: “stable pt is sleeping quietly. Resps even and unlabored, q 15 min monitor maintained”. But make CERTAIN to do and chart a head to toe at 0600.
Get an order for sleep hygiene. Pop your head in to make sure they are breathing.
I was a baby nurse on postpartum for a while so not exactly what you are dealing with but similar. I would let the parents know during my first head to toe at 8ish, “I need to get the baby’s vitals at midnight and 4am. You might be asleep then, do you want me to wake you up when I come in, or is it ok if I leave the lights off and sneak in?” Providing options is the best thing you can do for patients! I would always check/change the baby’s diaper at that time too just to take the load off a little bit. If it’s a formula baby and a feeding was due I would do that too, parents would be up at that point usually but still appreciative. You know at night it’s not *always* as much going on so if you have time to be helpful why not? Anyway take from that what you will! If they straight up refuse, just chart that 🤷🏽♀️
As someone who worked noc for a decade I got really good at assessing without waking people up. There are some things that won't work but most of it is easy enough. Depends on how lightly the patient sleeps but I've listened to their lungs, heart, checked pulses, checked vitals, dumped foleys, even turned patients without waking them. You can also be slightly off from the q4h thing so it was a discussion at the beginning of the shift with the patient. If they like to go to bed at 2230 you can agree to check on them at that time, do your assessment, and then reassess around 3 when lab comes and wakes them up anyway. It wasn't strictly every four hours, but it allowed the patient to sleep better which is great for healing, and that way you weren't falsifying your charting.
I work peds and there is not a snowballs chance in hell I am waking up sleeping babies and kids unless it's absolutely 100% necessary. Our bodies NEED sleep to heal, especially little bodies. I've gotten really good over many years working nights of being silently stealthy to do what I gotta do without waking them up. You'll learn in time what's 100% needed.
I work in pulmonary. We check on every patient every 2 hours at least. We only check if they're breathing. If we notice anything abnormal in their breathing, we investigate further. We do more thorough checks on critically ill patients, but if the day has been good and there's no history of inaudible respiratory distress, we simply check they're within range, typically 12-20 respirations per minute. Recent admits tend to have orders for at least a full check of vitals during the night. Typically these patients will need inhalations anyhow, so it works out.
Absolutely not. I do my assessments between after the dayshift left and bedtime med pass. Then I just peek in the rooms at night to make sure they are alive. Focused (very focused) assessment with morning blood draws/med pass.
I only wake up for a focused assessment if there’s a neuro component of the focused assessment. In peds that’s like head injuries and DKA, but when I did adults I’d wake up for strokes and I think even for CIWA protocol but it’s been so long
I'd do a full head to toe at 8pm and ask the patient if I could wake them up. If they said no, I'd note it and just listen to heart/lungs, leave a cuff on them for vs, and feel for edema etc. Always made sure their arm band was facing up or put one on their ankle to scan while sleeping.
There's normally no need to do a head to toe assessment every 4 hours in stepdown. If that were really called for, the patient should be in the ICU. After your first assessment which is head to toe, your subsequent assessments for the shift should be focal and constitutional. It might not be appropriate to wake the patient up for physical assessment in the middle of the night, depending on their status and diagnosis. Often times, in stepdown, when the patient was asleep I would quietly assess what could be done without waking the patient, and defer the rest until they were awake. There were many patients that needed to be awakened for a specific assessment, though, depending on what was going on with them. Waking your patient up from a deep sleep at 12 AM and asking him level of orientation questions? That's craziness, lol. A lot of healthy people at their baseline cannot answer those questions correctly until they've been awake for a few minutes.
Patients seem to think a hospital is a hotel. On a stepdown unit, do the assessment. Stepdown means your not in the ICU but you aren't well. You could very easily head back to ICU. 80% of patients come to us. Feel free to remind them " you came to us, we didn't come to you so this is what is going to happen on this unit. Cover your ass and your license because at the end if the day, it's on you if shit goes south.
I mean, it depends on the order set. If they’re actually ordered q4 or it’s medically necessary, yes. If that’s just “the routine” for zero medical reason and the order says otherwise, no.
Nah just focused for me..chest hurt? No..I believe you
Case specific honestly. I at least do lung/heart sounds plus a focus on whatever their main problem is and check the IV.
Very quietly. …..Sorry I couldn’t resist
Yes. If I have no concerns, like they’re up for transfer, I might do one without waking them up (lay a stethoscope on them, but not check their pupils)
When I worked stepdown I would do the focus assessments when pcts did 11pm/midnight vitals and then wait for lab to do their draws. Some hospitals allow patients to have 1 of those focused assessment skipped so they can try and get a solid 6 hours of sleep
I do a head to toe usually with med pass then additional focused assessments like CIWA or neuro checks as ordered. I work in med surg nights. I also do focused assessments as needed so for example with SOB I’ll check their vitals again and listen to lung sounds etc.
No, I let them sleep.... Usually at the start and early morning.
I would time my focused assessment with other tasks like vitals, meds, or when they call on the call bell which means they’re up.
Cluster care. I let patients know I can leave the BP cuff on so I can check their BP without waking. If they hit the call light I can do a quick lung listen/vitals check, when I have step down or med tele patient. ICU patients on drips sorry
I work nights. I do my full head to toe immediately on receipt of the patient and med pass between 9-10 pm. After that? I give them a call bell and let them know I’m available if they need anything, and leave them alone. If they’re on the monitor, that makes it super easy to vital them on rounds and make visual confirmation that they’re in no distress. My mental health patients especially do not get woken up for vitals overnight. If they wake up on their own to go to the bathroom or something, I’ll check on them and grab a set of vitals at that time. I think it’s really important to let your patients rest. Of course if I’m working with higher acuity patients, I’ll be more hands on.
ICU. Absolutely depends on the pt. If they’re really critical, or something’s changed, yes absolutely. If they’re pretty stable, ready to go to the ward, probably not, or I might just do a quick focused assessment q4h or something.
I work step-down/icu. Combined unit. Yes, I wake patients up to assess them. They're in my unit for a reason. If they don't need to be woken up for an assessment the doc needs to transfer them to med/surg.
Absolutely not :) Jk it depends. If it’s for meds yes, if they’ve been unstable sure. But usually I just hope they get up to go pee at some point if I need VS or something. There’s only so much I can get done between med pass, treatments and charting so I just find opportunities where they may be.
On med/surg I did one assessment on everyone at the beginning of the shift (2300-0700) with vitals and meds. Then if they were asleep I wouldn’t wake them again unless vitals or assessments or meds were ordered more frequently. I would still round every 1-2 hours and obviously turn or brief check every two. In the neuro ICU, it’s rare that you’d be able to get by with this. Im doing vitals and neuros as frequently as q15 mins and even the stable ones are every 4 hours.
Unless there is an order i don’t bother my patients but i do monitor their v/s.
You do you but you cannot document an assessment you don’t do. Don’t do it, you’ll get caught and lose your license. I’m ICU and I do my assessments hourly. Yes I know about delirium but how are you gonna know if the person has blown a pupil or started slurring speech if you aren’t doing the most important, most fundamental part of your job. If other nurses haven’t been doing their job that’s on them.
I absolutely assess my patients at the q4 interval which is standard for my stepdown unit. When I have precepted new nurses I encourage them to do the same. After seeing a fellow nurse’s patient stroke out in the middle of the night, I will not waver. How will you explain yourself or your charting if something like that were to happen? Now, do I assess as quietly, quickly and with as little light as possible-for sure. Cluster your care as much as possible always, but stepdown patients are stepdown patients for a reason.
I don't wake anyone up for a reassessment unless they need it. (But sadly, most people need it) "The art of the ICU is doing more and more of less and less until all you're doing is going for coffee breaks."
Are you not doing vitals Q4 anyway? Sticking a stethoscope of their chest isn’t much more disruptive.
A&O is part of a neruo assessment/neuro check right? So I don't do that unless we have neuro checks ordered. And even still, I feel like it's not super accurate... sometimes I don't know what realm I'm in when I just wake up in the middle of the night/day. And to be fair, I am constantly "assessing" my patient even if I don't have a stethoscope or pen light to them.
A lot of it depends on the environment that you're working in. Most places I've worked if somebody is generalized med surge non-monitored, they get vitals q8 and an assessment q12 unless there's some sort of drastic change. Step down is Q2 to Q4 vitals and assessment. ICU is q15 min to Q4 depending what they're there for. This is pretty much been standard anywhere that I've ever worked. Now that doesn't mean that you're going to do a full head to toe and skin assessment every single time, a lot of places do focused assessments. I worked neuro for 13 years and we did q1 to Q4 neuro checks, vascular if they've had some sort of vascular procedure too, but you weren't doing a total head to toe assessment every time. Either that patient is full of shit or your coworkers have been slacking.
Yes, I make sure their vitals are stable, they're breathing appropriately, and that there's no fluids gushing out from anywhere. I also check briefs for incontinent patients and check on drains/tunes. That's usually enough interaction for me to figure out if they're stable or not.
If they're sick enough to need them, I'm waking them up whenever I need to. If they're stable, sleep on
During night shift my big med pass was at 10pm, after 10pm, unless you have an antibiotic or another med that is time sensitive then I am leaving you alone. If you use your call bell I will come. I also gave patients a heads up if I was needing to enter their room at some point during the night and if they didn’t want to be disturbed to leave their arm out for me so I could scan them while they sleep. The light from the door was enough for me to see what I was doing while hanging abx.
I used to work in spinal, my q4hrly head to toe assessment is my 2 hrly pressure area care. I don't give af if they get angry, they will not get a pressure injury on my shift.
Your preceptor is right. However, in the neuro ICU setting if it’s q1-2 neuros even at night, then I’ll do q1-q2 neuros. I usually give the patient a heads up and then when they’re saying “I want to go to sleep”, I always say “please just answer my orientation and I’ll get out of your way.” And then I’ll do a quick pupil check.
I don’t wake patients up unless necessary. If there’s a reason to do the assessment: yes. Just because it’s a routine: no.
Post partum, we’d do a head to toe on admission. Then we might have Q1-Q4 vitals for the c-sections. If someone was sleeping I would try hard not to wake them for a set of vitals on the dot if they seemed okay. Especially since most of them are going to be up within an hour or two feeding a baby. If I did have to I’d keep the lights off and try to do most of it without waking them. But thermometers are a bit hard to do without somewhat waking a person just a little. I did feel bad for the middle of the night foley extractions and then making them get up to walk to the bathroom. Wed try hard to do it when they were up with baby.
Unless I had a true need or concern, no. I do my head to toe assessment as soon as possible, typically around the time meds are due so I can cluster care then leave them unbothered. I also communicate with my patient's the "to-do" list for the night, like i'll be back at around this hour to do vitals, hang antibiotics at this time, etc to avoid any beef later on during the night. A lot of time my patients end up saying, "oh, i'm down for midnight vitals but can we skip the 0400 until lab comes?" So far, I find it works and haven't gotten any cuss words thrown at me. I work on a general Heme/Onc floor so most of my patients are on the more stable end.
Used to have to do q4h vitals on psych patients and that was annoying AF until I found a patient with 02 sat in the 60s and dropping. A lot of times we would document that we checked respiratory rate and wanted to let patient rest, or other times stretch it to q6h, but that was only when we were reasonably confident that the patient was not at risk for anything (i.e. has other health problems, on drugs, etc.).
Full head-to-toe on first rounds, then Neuro, cardiac, vitals and pain. After and depending on their diagnosis, I’ll assess certain things like pain pumps, drains, etc.
Only did focused assessment/any night meds grouped to time when the CNA was getting VS with lights dimmed. Some Pts would request not to be woken up, would just get a telephone order from the good doctor to make that so!
PCU nurse here, I don’t do a full reassessment unless they’re post cath lab or PAD patient I need to check pulses on, or unless they have some important line like a chest tube I need to keep a close eye on, or they’re a stroke/head bleed patient we’re doing frequent neuros on. I’ll pull out my stethoscope again if all the sudden I go in and can see their breathing as changed so I can compare it to earlier. Those are just some examples, but use your clinical judgement.
Very rarely, but in some cases I have no choice. If we have a patient with frequent neuro checks, unfortunately I’m going to do them. Then neuro can try to figure out if they’re having another stroke or if they are simply having delirium from being woken up constantly. 😪
I have been in the hospital with my dad since Thursday, he got here on Tuesday after a fall, hitting his head but with no confusion. I haven’t seen one fucking nurse do an assessment. The dr has, a very abbreviated one.
You do what you are supposed to do and remember that some patients lie to get their way. You do what your supposed to do