Look under the covers! A systematic approach to assessing the cardiac surgical patient's condition

Abstract Introduction Accurate and safe assessments promote trust and security between the patient and nursing staff. The department lacked a systematic approach to assessing patient's condition. The nurse's assessments were mainly based on medical records and previous verbal reports. Usually, nurses do several diffrent assessments throughout the day. Head to toe (HTTA) is a physical examination with inspection, palpation and auscultation combined with a patient dialogue. The primary aim is for conditions and complications to be detected earlier or even avoided. The aim was to make all assessments of the patient at one time, to increase patient safety, to make assessments bedside to increase person-centered care. Method This was an improvement work, where an extensive literature search was conducted. An introduction plan was made. A questionnaire was conducted to be used before and after the implementation of HTTA. A documentation template was constructed in the charting system. Result After the intervention nurses largely perform HTTA on patients. They feel that it is a good way of working that helps them to get a good status on the patients. The nurses felt more prepared for the rounds when HTTA is done than before. 72% stated that they perform HTTA on patients who come from other units. The patients experience the assessment as "someone is looking at me the whole me" and "it felt good and that they probably took my body seriously". Discussion Adjustments in other working methods (medications are distributed, adjusting times for pain relief administration) is necessary to facilitate the implementation of HTTA.