Head to Toe Assessment

No, I'm at UNDA :)

shibz...try to use data from obs to expand from there. This is the clinical notes. Then you can add activities of daily living..it might sound trivial but a pat who can do these activities present as independent and cognitively intact. Next input what work needs to be done and what results were received from external test...CXR, MRI and etc. If you attended ward rounds...note doctors' instructions or change in meds.

Different wards may have different data input..in ICU doe example the progress notes is much more detail. what is PEEP, PIP, tidal volume set at for mechanical ventilation and etc. Good luck..hope this helps

Sorry, I'm a volunteer (unpaid) AIN (nursing assistant), who helps out family and friends wherever possible. I take obs, but I don't record them electronically, only on scrap paper for future reference (written clinical notes on friends, patients, family etc.) I get bored easily, so I'm currently monitoring my own vital signs, lol! It's quite fun to see the changes and record them when it's actually relevant to your personal health and wellbeing. For example, my temp. in degrees Celsius was 33.4 last night, but 34.9 today, but are 3-4 degrees too low but non-life-threatening, just due to the heat and the constant air-con, plus 2L water daily which I drink to keep cool. My pulse is slightly delayed at 50 beats per minute, non Shiz, why would that be given that I have a BMI of 19, am 17 years old and a full-time, stressed out student?

Seriously, answer me - is it stress, age, height and weight (BMI), or all of the above? These are the basic life support skills that a third year nurse such as yourself should have, you really need to study hard and get your act together OR YOU ARE GOING TO BE A DANGER ON THE WARDS!

We have enough bad nurses all ready, knuckle down because vital signs isn't meant to be the most difficult aspect of nursing - administering insulin injection to patients with Type I Diabetes is much more difficult, as is restraining a schizophrenic to inject a sedative or antipsychotic, e.g. Risperdal (risperidone 10 mg - 30 mg). The clinical aspects, not ADL's and taking obs (a clinical but non-emergency skill set) should not so much more difficult. I'm an AIN and I regularly taking obs in family and home care envioronments, as well as taking blood (I'm going to do a course thru' the SAN when I turn 18 to do bloods, urine, stools, sweat, semen, vitrial fluid, bone marrow, etc.)

PLEASE, PLEASE, PLEASE GET YOUR OBS/HEAD TO TOE ASSESSMENT DOWN-PAT. You owe it to your patients and senior nurses, a graduate nurse who can't take obs is, put simply, a disgrace to the nursing education sector and evidence that moving nursing out of hospitals and into universities was a massive mistake by nurses and the government.

shizzy?...are you referring to me or Shibz? Yes, I agreed with you, reading ECG does not take 6 years. But to learn BASIC ECG, its 1 full semester. Covering your usual rhythms, AV blocks, Bundle Branch Blocks including fasicular bocks, Wolff Parkinson White, Atrial and Ventricular hypertrophy, identifying long QT (risk of R on T), hyper and hypo kalemia, abnormal p waves (p Mitral or bi-phasic or tall and tented) - indicating mitral valve stenosis or enlargement, pacing capture, right or left axis deviation, ST elevation or depression, early ST take off, ischemia or infract and etc etc. Yes...you are right about learning to read ECGs...but not everyone can read ECGs in depth. Sadly ECG reading by itself is not necessarily sufficient to identify myocardial infarct. Even slight elevation of troponin levels is not indicative....Sometimes we need to do a Myocardial Perfusion Scan to determine if the patient is positive for cardiac disease. MPOS is done as it is non invasive..if this is positive then we progress to an angiogram and onwards.

Well being an RN, I would believe that one would be able to sufficiently interpret blood results and etc.

@Upcoming RN, Do you know how to read ECG yourself? Sounds like you know your stuff and I am impressed...did you learn Bazzet's formula for determining long QT - QT/square of RR, in your ECG training? cheers

Upcoming RN, I think its not a good idea to suggest impressing someone with being able to "read" ECGs unless they are adequately trained to do so. Sudden dips or rises in ECGs does not necessarily mean that they are abnormal. The basic rule of ECG reading is whether the patient presents with symptoms. Example..If you look at older people, most of them have "abnormal" ECGs - most common "abnormalities" are - Atrial fribillation, 1 degree AV block, 2nd degree AV block (Type 1 and 2), Bradycardia, escape junctional beats, inverted T waves (ischemic disease), wandering pacemaker and etc. But most will present without any problems. Even with people with Wolff Parkinson White but is asymptomatic, doctors will not ablate the bundle of kent to control the aberrant conduction. Usually people with WPW will show signs of syncopy and/or tachcardia around early teens 15 to 20s. If these signs do not manifest, these people usually would be allowed to live with their aberrant conduction and I have seen one case of a 40 plus man with WPW.

What I am saying is unless student nurses study how to read ECGs properly, I caution against trying to show off and misread a pattern. Believe me, it can be easily done...take for example Atrial Fribillation and Atrial Flutter...they both look almost alike...text books will say that the difference is the saw tooth presentation in flutter. I have seen flutters that do not have the distinct saw tooth but irregular waves like a fribillation...the only way to differentiate was the regularity of the rhythm.

Good luck

shizzy?...are you referring to me or Shibz? Yes, I agreed with you, reading ECG does not take 6 years. But to learn BASIC ECG, its 1 full semester. Covering your usual rhythms, AV blocks, Bundle Branch Blocks including fasicular bocks, Wolff Parkinson White, Atrial and Ventricular hypertrophy, identifying long QT (risk of R on T), hyper and hypo kalemia, abnormal p waves (p Mitral or bi-phasic or tall and tented) - indicating mitral valve stenosis or enlargement, pacing capture, right or left axis deviation, ST elevation or depression, early ST take off, ischemia or infract and etc etc. Yes...you are right about learning to read ECGs...but not everyone can read ECGs in depth. Sadly ECG reading by itself is not necessarily sufficient to identify myocardial infarct. Even slight elevation of troponin levels is not indicative....Sometimes we need to do a Myocardial Perfusion Scan to determine if the patient is positive for cardiac disease. MPOS is done as it is non invasive..if this is positive then we progress to an angiogram and onwards.

Well being an RN, I would believe that one would be able to sufficiently interpret blood results and etc.

@Upcoming RN, Do you know how to read ECG yourself? Sounds like you know your stuff and I am impressed...did you learn Bazzet's formula for determining long QT - QT/square of RR, in your ECG training? cheers

Sorry, I should have been more clear. I did not mean that I can read an ECG as well as a doctor. I meant that I can look at it and know whether or not something is wrong. I haven't done a ECG course, and I'm sorry if I said I had - I just ask my doctors a lot of questions (lol) and I am also doing HSC year 12 Biology, in which have learnt about health and body systems as part of the Maintaining a Balance module. Sometimes I get ahead of myself and imply that I know more than I actually do. It's only because I like to impress people ...

If I looked at an ECG, and it showed a heart attack, I think I would pick that up. If it showed the tiny problem mine did (I have a pectus excavatum of 'dent' in my chest which appears to cause chest and back pain)... that would also be something I may pick up. I would love to do an ECG interpretation course - do I need to wait until I start my UTS nursing degree? (I think I can learn how to perform an ECG and collect bloods without being a student nurse, TAFE just didn't want me for their Cert 2 in Pathology for some reason)

Anyways... email me or reply here (preferably here as my email, jrschofield93@yahoo.com.au) has been having issues with receiving emails from my year 12 Italian Extension teacher)

Just on a side note, I speak Italian quite well, is that a good skill for a nursing - would I get to speak it in my practice in a surgical ward or community health, perhaps? :)

So just to clear this up, Schizo, are you an RN? (I read so much information just now that I can't remember what you do)

I am somewhat aware of how to set up an ECG. I have had two done. The first by a pathology collector trainee (who did not have her Cert 3 in Pathology yet), the second by an older RN (possibly a hospital-trained nurse - she is a practice nurse now) who used 12 leads (or thereabouts, there were a lot of leads, on my legs, chest, maybe arms). Let me just say - the RN did the ECG so much better. She was older (the pathology collector was only 22, the nurse 45+), more experienced (not a trainee!), used the correct amount of leads, knew which side each set of leads went on. The nurse even kept fussing over me, making sure that I was comfortable - didn't even need to take my shirt all the way off.

There's something you have to do with the 12 leads - Janet or Vicki said that she once 'reversed the cords' and 'the doctor had to work very hard to find out what was wrong with his poor patient'. Can you explain why this is an issue? Is it to do with the atriums of the heart - or maybe the ventricles? I'd love to meet someone like you. I know a 22-year-old nurse but she didn't want to talk about work last time I saw her (had a minor prang on the way to hospital, she did) - she's in casualty.

I suppose I look at nurse training and wonder - why on Earth did we go from learning on the job 30+ hours per week, for most weeks of the year - getting paid... to the shit system we have now where (I think) you're can only learn to do venipuncture or injections after a year of ADL's and basic obs? Now you incur a debt to the government ... it's just wrong and a lot of the care is going out of nursing. Now there's so much theory and not even one year's worth of prac throughout the entire degree! The highest we have in Sydney is Notre Dame with 33 weeks of prac over three years.

While impressing people is all well and good - what my purpose is, is to look after people. Being arrogant is not a part of my philosophy and never has been. For as long as I can remember, I have been the kid at school who knows everything, 'the nerd'. It's not an issue in year 12, but maybe I am too smart for my own good. There are all these walls, rules, boundaries that I can get over - I wanted so badly to do my Cert 3 in Aged Care instead of Year 12... I could have moved on to Dip Nurs by now... instead I'm stuck at school, learning things that generally aren't very difficult at all. I take my own obs (temperature, pulse, tried taking my own BP but being right handed somehow could get the cuff on) just to try something more challenging. Stuck in a casual job where they'll only give me one shift a week... and I'm not helping anyone.

I want to be like you - read ECG's, take advanced obs. It upset me when you said that I probably didn't have any experience in taking obs because that is only partly true. I have been poked and prodded enough as a mental health patient to know basic vital signs. The things is - intracranial pressure - is that a vital sign? How are you going to check that in an emergency without wasting time...? It's like you are actually showing off to me and rubbing it in my face that you know more than me. If becoming an RN means regularly coping on the chin the flack I got from you, Schizo, just because I try to share my knowledge and help out... well, take me off the sign up list, thanks. There's a difference between being arrogant, and sharing as much knowledge as you can in an attempt to help, even if you do fall flat on your face and find out you got it wrong.

On this forum, we're all either nurses, student nurses, aspiring nurses, patients or just consumers - we need to help each other out rather than sarcastically launder our knowledge over the less experienced, which is what you have done in previous posts, Schizo. Nurses do it because they care, and part of care is teaching others. Both you and I have attempted to do that, and I don't believe either of us was successful or compassionate in our approach, regardless of our differing levels of experience.

Wow Shibz1989, looks like your thread has been completely hijacked!!

@ Upcoming RN. Wow...long post and hopefully I can reply everything you asked me. FIRSTLY...MY APOLOGIES TO shibz for hijacking thread.

1) Yes, I am a Registered Nurse

2) I have worked in ED and ICU

3) I was once a General Manager in charged of a group of companies in Asia Pacific region and gave all that up to be an RN because like you I wanted to help others. All my friends thought I was crazy to take such a huge pay cut...but at least I am Happy doing what I am doing now.

4) Identifying long QT is an analytical procedure to determine risk of patient developing an R on T and going into possible fatal arrhythmias. If you identify one, you look at previous ECGs to determine if it was genetic or causes by medications. If caused by meds, then change meds. We don't worry about long QT in full blown MI.

5) LOL..The most common mistake is to believe the 12 lead ECG is made up of 12 leads...Count it and you'll find that it NOT 12 leads. Example - the leads are Right Hand, Left Hand, Right Leg, Left leg, V1, V2, V3, V4, V5 and V6 : Total 10 leads. The reason why its called 12 leads is because 2 leads are bi-polar and read both directions. The 12 lead ECG is more accurate in identifying condition than a 3 lead which is used for emergencies because its easier to set up...paramedics used 3 leads..to them an infarct is an infarct and patient needs emergency care...no time to look at where its located. The 12 lead is better in the sense that ti helps identify other conditions like 3 rd degree AV block....If present then certain drugs are contraindicated..example use of digoxin in presence of AV block.

6) The position of the leads tells us the progression of conduction and in a way even helps us identify position of an Infarct. Example, infarcts are localized...so if you see ST elevation in V1, V2 and V3...you'll know the infarct is antero septal. Look at the position of the lead placement and where it reads the infarct, thats where it is.

7) Reversing the leads is common mistake...look at avR and if your waves are upright, you know you are screwed...lol.

8) Stay in year 12 and complete your studies there...then move on to University and do your degree....you will do well. Its ok to be a nerd, only how you present yourself that you need to be mindful. What you wrote in reply to shibz1989 was pretty condescending...shibz is already on the path to being a nurse and I have a lot of respect for that not to assume that just because I am an RN, that I know more. You came across as someone who is trying to tell Shibz what to do when you have limited experience.

9) James, sometimes we do things that defies logic...56 days ago one of my patient went into septic shock just as I got on. After all the interventions, we actually reduced the number of obs because it distresses the patient's family members and also the patient too..but we might say without obs how are we to know if her condition is improving or going south? Well we have already done all we can and if she goes south, she goes south. Cheerfully the patient recovered. Another thing, the obs we mention is always "assumed" to be temperature, Heart rate, BP, SaO2, HR rhythm, urine output and GCS. But what I am trying to tell you is that sometimes there are other obs that we need to do...head to toe, arterial blood gas and etc etc.

10) Yes, I was sarcastic at you earlier...that was because you lorded over Shibz with your post about how important it is to do obs and rah, rah about being a good nurse. James, to be a good nurse, you need to be mindful of what you say and how you say it. You have been rude to me on another thread asking if I was a diagnosed shizophrenic and proceeded to tell me how pathetic nursing can be...cleaning up poo and emptying stoma bags. Well, you assumed that I am a mental case...ok...maybe but never diagnosed...lol but to say that i don;t know what nursing is all about? Well, you just assumed and looked what it got you into....."Quirks" got up at you. So don't be arrogant or someone with a bigger stick will come looking for you...and I say this because I care enough to acknowledge that you can become a great nurse, given your propensity to learn and desire to excel. But do temper it with caution...books alone is one thing but experience adds the extra dimension which books cannot tell you. Even though my pet subjects are wound care and ECG, I often quietly listen to differing opinions and try to learn why their diagnosis is of such. May not agree with some but then again its NOT an exact science. Yes, I was "rubbing" it in your face but it was a reaction to your showing off. As you can see, after your immediate reply, I can see that you have a good heart and I wished you "well done".

11) I am pursuing my masters to be a nurse practitioner if you want to know what I am doing...just learning to better serve my fellow human kind.

12) Intercranial pressure (ICP) is a vital sign. In head trauma, you don't increase nor decrease in pressure...it is usually put in in emergencies before transferring to ICU. James, you need to know that you CANNOT simply assume a scenario that in emergencies, you don;t want to monitor such and such a vital sign, this is because the situation changes fluidly, so to dissect it specifically to one particular moment in the course of events and ask, "Do you really think its wise to have an ICP monitoring when all hell is loose?" is NOT critical thinking...somewhere down the line it may need to be done...maybe not immediately in emergency but maybe later. Likewise I say to you, you see a slight ST elevation, do you say that's an Infarct? One needs to back that up with whether troponin or creatine levels are up...even if they are not up, it does not mean there's no infarct because troponin appears later when heart muscle/cells die.

13) Do you think I am arrogant? I shared with you about ECGs to give you an idea that its NOT so simple as you put it...its not being able to read some bits and pieces of an ECG trace to impress your facilitator. With limited knowledge, it can be misplaced confidence. For example, if you see ST elevation in all leads, you might immediately say...INFARCT!!! Well, its probably more pericarditis because in MIs its ALWAYS localized. So imagine a nurse who has limited knowledge and identifies this ST segment elevation can calls a code...how silly would he/she look? All she need to do is ask the patient to sit up and lie down...patient would feel positional chest pains. I am only trying to encourage you to gain all the knowledge you need to be the better nurse...I am impressed by your knowledge but you still need to temper it with experience and "more" complete knowledge to be the exceptional person you are.

14) Bazzette formula - well just say I don't know my maths...lol. But to tickle you here's wikipedia for you - http://en.wikipedia.org/wiki/QT_interval

Cheers
Undiagnosed Schizoprehic

12) You