Nursing Assessment

Nursing Assessment

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Treasure Island (FL): StatPearls Publishing ; 2022 Jan-.
Assessment (gather subjective and objective data, family history, surgical history, medical history, medication history, psychosocial history)
Analysis or diagnosis (formulate a nursing diagnosis by using clinical judgment; what is wrong with the patient)
Planning (develop a care plan which incorporates goals, potential outcomes, interventions)
Implementation (perform the task or intervention)
Evaluation (was the intervention successful or unsuccessful)
Appropriate level of care to meet the client's or patient’s needs in a linguistically appropriate, culturally competent manner
Assessment and reassessment once admitted
Admission history and physical assessment as soon as the patient arrives at the unit or status is changed to an inpatient
Data collected should be entered on the Nursing Admission Assessment Sheet and may vary slightly depending on the facility
Additional data collected should be added
Documentation and signature either written or electronic by the nurse performing the assessment
Documentation: Name, medical record number, age, date, time, probable medical diagnosis, chief complaint, the source of information (two patient identifiers)
Past medical history: Prior hospitalizations and major illnesses and surgeries
Assess pain: Location, severity, and use of a pain scale
Allergies: Medications, foods, and environmental; nature of the reaction and seriousness; intolerances to medications; apply allergy band and confirm all prepopulated allergies in the electronic medical record (EMR) with the patient or caregiver
Medications: Confirm accuracy of the list, names, and dosages of medications by reconciling all medications promptly using electronic data confirmation, if available, from local pharmacies; include supplements and over-the-counter medications
Valuables: Record and send to appropriate safe storage or send home with family following any institutional policies on the secure management of patient belongings; provide and label denture cups
Rights: Orient patient, caregivers, and family to location, rights, and responsibilities; goal of admission and discharge goal
Activities: Check daily activity limits and need for mobility aids
Falls: Assess Morse Fall Risk and initiate fall precautions as dictated by institutional policy
Psychosocial: Evaluate need for a sitter or video monitoring, any signs of agitation, restlessness, hallucinations, depression, suicidal ideations, or substance abuse
Nutritional: Appetite, changes in body weight, need for nutritional consultation based on body mass index (BMI) calculated from measured height and weight on admission
Vital signs: Temperature recorded in Celsius, heart rate, respiratory rate, blood pressure, pain level on admission, oxygen saturation
Any handoff information from other departments
Cardiovascular: Heart sounds; pulse irregular, regular, weak, thready, bounding, absent; extremity coolness; capillary refill delayed or brisk; presence of swelling, edema, or cyanosis
Respiratory: Breath sounds, breathing pattern, cough, character of sputum, shallow or labored respirations, agonal breathing, gasps, retractions present, shallow, asymmetrical chest rise, dyspnea on exertion
Gastrointestinal: Bowel sounds, abdominal tenderness, any masses, scars, character of bowel movements, color, consistency, appetite poor or good, weight loss, weight gain, nausea, vomiting, abdominal pain, presence of feeding tube
Genitourinary: Character of voiding, discharge, vaginal bleeding (pad count), last menstrual period or date of menopause or hysterectomy, rashes, itching, burning, painful intercourse, urinary frequency, hesitancy, presence of catheter
Neuromuscular: Level of consciousness using AVPU (alert, voice, pain, unresponsive); Glasgow coma scale (GCS); speech clear, slurred, or difficult; pupil reactivity and appearance; extremity movement equal or unequal; steady gait; trouble swallowing
Integument: Turgor, integrity, color, and temperature, Braden Risk Assessment, diaphoresis, cold, warm, flushed, mottled, jaundiced, cyanotic, pale, ruddy, any signs of skin breakdown, chronic wounds
Complete an initial psychological evaluation; screen for intimate partner violence; CAGE questionnaire and CIWA (Clinical Institute Withdrawal Assessment for Alcohol) scoring if indicated; suicide risk assessment
Provide a certified translator if a language barrier exists; ensure culturally competent care and privacy
Ensure the healthcare provider has ordered the appropriate tests for the suspected diagnosis, and initiate any predetermined protocols according to the hospital or institutional policy
P: What provokes symptoms? What improves or exacerbates the condition? What were you doing when it started? Does position or activity make it worse?
Q: Quality and Quantity of symptoms: Is it dull, sharp, constant, intermittent, throbbing, pulsating, aching, tearing or stabbing?
R: Radiation or Region of symptoms: Does the pain travel, or is it only in one location? Has it always been in the same area, or did it start somewhere else?
S: Severity of symptoms or rating on a pain scale. Does it affect activities of daily living such as walking, sitting, eating, or sleeping?
T: Time or how long have they had the symptoms. Is it worse after eating, changes in weather, or time of day?
E: Events before the acute situation
Clenching of the teeth and facial expressions
Tachycardia or blood pressure changes
Panting or increased respiratory rate
Clutching or protecting a part of the body
Decreased interest in activities, social gatherings, or old routines
Environmental concerns, home safety
Domestic and family violence risk, human trafficking risks, elder or child abuse risk
Suicidal ideation (initiate suicide precautions as directed by institutional policy)
Active, attentive listening: Attention to the details of what the patient is saying either in a verbal or nonverbal manner
Reflection, share observations: Repeat the patient’s words to encourage discussion, state observations that will not make the patient angry or embarrassed; i.e., " You seem tired today, sad...," " You have hardly eaten anything this morning."
Empathy: Demonstrate that you understand and feel for the patient, recognition of their current situation and perceived feelings, and communicating in a nonjudgmental, unbiased way of acceptance
Share hope: Ensure in the patient a sense of power, hope in an often hopeless environment, and the possibility of a positive outcome
Share humor: Fosters a relationship of emotional support, establishes rapport, acts as a positive diversion technique, and promotes physical and mental well being. Cultural considerations play a role in humor
Touch: Touch may be a source of comfort or discomfort for a patient, wanted or unwanted; observe verbal and nonverbal cues with touch; holding a hand, conducting a physical assessment, performing a procedure
Therapeutic silence: Fosters an environment of patience, thought and reflection on difficult decisions, and allows time to observe any nonverbal signs of discomfort (the patient typically breaks the silence first)
Provide information: During an assessment and care, inform the patient as to what is about to happen, explain findings and the need for further testing or observation to promote trust and decrease anxiety
Clarification: Ask questions to clear up ambiguous statements, ask the client or patient to rephrase or restate confusing remarks so wrong assumptions are clarifiable and a missed opportunity for valuable information forgone
Focusing: Brings the focus of the conversation to an essential area of concern, eliminating vague or rambling dialogue, centers the assessment on the source of discomfort and pertinent details in the history
Paraphrasing: Invites patient participation and understanding in a conversation
Asking relevant questions: Questions are general at first then become more specific; asked in a logical, consecutive order; open-ended, close-ended, and focused questions may be useful during an assessment
Summarizing: Provides a review of assessment findings, offers clarification opportunities, informs the next step in the admission and hospitalization process
Self-disclosure: Promotes a trusting relationship, the feeling that the patient is not in this alone, or unique in their current circumstances; provides a framework for hope, support, and respect
Confrontation: You may have to confront the patient after a trustful rapport has been established, discussing any inconsistencies in the history, thought processes, or inappropriate behavior
Ethnic origin, languages spoken, and need for an interpreter
Primary language preferred for written and verbal instructions
Special food requirements, dietary considerations
Cultural customs or taboos such as unwanted touching or eye contact
Skin condition such as signs of breakdown or chronic wounds
Overall mood and psychological state
Initial vital sign measurements: temperature recorded in Celsius in most institutions, respiratory rate, pulse rate, blood pressure with appropriate sized cuff, pulse oximetry reading and note if on room air or oxygen; accurately measured weight in kilograms with the proper scale and height measurement, so body mass index (BMI) is calculable for dosing weights and nutritional guidelines
Look at all areas of the skin, including those under clothing or gowns
Ensure patient is undressed, allowing for privacy, uncover one body part at a time if possible
Be alert for any malodors from the body including the oral cavity; fecal odor, fruity-smell, odor of alcohol or tobacco on the breath
Compare one side to the other, and ask the patient about any asymmetrical areas
Observe for color, rashes, skin breakdown, tubes and drains, scars, bruising, burns
Document pertinent normal and abnormal findings
Temperature and moisture (warm, moist or cool, and dry)
Good striking and listening technique
Especially important in the pulmonary and gastrointestinal systems
Dull, flat, resonance, hyper-resonance, or tympany sounds
Percussion is an advanced technique requiring a specific skill set to perform. Therefore, it is a skill practiced by advanced practice nurses as opposed to a bedside nurse on a routine basis
Listening to body sounds such as bowel sounds, breath sounds, and heart sounds
Important in examination of the heart, blood pressure, and gastrointestinal system
Listen for bruits, murmurs, friction rubs, and irregularities in pulse
Physical exam length can vary depending on complexity
Physical exam extends from passive observation to hands-on
Avoid long fingernails to prevent patient injury during the exam
Palpate areas that are tender or painful last
Be alert for any signs of maltreatment or abuse, and follow mandatory reporting guidelines
Abdominal assessment follows the techniques in this sequence: inspection, auscultation, percussion, and palpation
Auscultate bowel sounds for at least 15 seconds in each quadrant using the diaphragm of the stethoscope, starting with the lower right-hand quadrant and moving clockwise
If a fistula is present for hemodialysis, assess for a thrill or bruit, document presence or absence. Notify managing healthcare provider immediately if absent
Steps in a comprehensive lung exam include PIPPA; Positioning of the patient, Inspection, Palpation, Percussion, Auscultation
Blood tests (CBC, chemistry, bedside glucose, pregnancy test, urinalysis, cardiac enzymes, coagulation studies)
Imaging studies (X-rays, CT, MRI, ultrasound)
Other diagnostic studies (ECG, EEG, lumbar puncture, etc.,)
Transfer forms/EMTALA considerations
Discharge medications and instructions
Follow up information, referrals, hotline numbers, shelter information
Document verbalization that discharge instructions were understood by caregiver or surrogate
Provide translators and language appropriate discharge instructions or paperwork
Health questionnaires such as those that address recent travel and exposure risks
Waterlow or Braden scale for assessing pressure ulcer risk
Glasgow coma scale/AVPU for assessment of consciousness
Pain scales such as the Faces Pain Scale (FPS), Numeric Rating System (NRS), Visual Analogue Scales (VAS), Wong-Baker Faces Pain Rating Scale (WBS), and the (MPQ) McGill Pain Questionnaire
Standard vital sign flow charts for different age groups
The nurse should be familiar with the otoscope, penlight, stethoscope (bell and diaphragm), thermometer, bladder scanner, speculum, eye charts, cardiac and blood pressure monitors, fetal doppler and extremity doppler, and sphygmomanometer
Stretcher or bed for proper positioning during a physical exam
Hand hygiene products, personal protective equipment if required
Alcohol swabs, sanitizer, or soapy water to clean equipment after use, such as with stethoscopes, to decrease the likelihood of cross-contamination of pathogens from inanimate objects (follow any manufacturer guidelines or institutional policies)
Computer or paper chart to document findings
Calculation devices for BMI, conversion from pounds to kilograms, kilograms to pounds, Celsius to Farenheight
Dunham M, MacInnes J. Relationship of Multiple Attempts on an Admissions Examination to Early Program Performance. J Nurs Educ. 2018 Oct 01; 57 (10):578-583. [ PubMed : 30277541 ]
Allen E, Williams A, Jennings D, Stomski N, Goucke R, Toye C, Slatyer S, Clarke T, McCullough K. Revisiting the Pain Resource Nurse Role in Sustaining Evidence-Based Practice Changes for Pain Assessment and Management. Worldviews Evid Based Nurs. 2018 Oct; 15 (5):368-376. [ PubMed : 30160011 ]
Palmer RM. The Acute Care for Elders Unit Model of Care. Geriatrics (Basel). 2018 Sep 11; 3 (3) [ PMC free article : PMC6319242 ] [ PubMed : 31011096 ]
Jamieson H, Abey-Nesbit R, Bergler U, Keeling S, Schluter PJ, Scrase R, Lacey C. Evaluating the Influence of Social Factors on Aged Residential Care Admission in a National Home Care Assessment Database of Older Adults. J Am Med Dir Assoc. 2019 Nov; 20 (11):1419-1424. [ PubMed : 30926408 ]
Abdul-Kareem K, Lindo JLM, Stennett R. Medical-surgical nurses' documentation of client teaching and discharge planning at a Jamaican hospital. Int Nurs Rev. 2019 Jun; 66 (2):191-198. [ PubMed : 30734275 ]
Gray LC, Beattie E, Boscart VM, Henderson A, Hornby-Turner YC, Hubbard RE, Wood S, Peel NM. Development and Testing of the interRAI Acute Care: A Standardized Assessment Administered by Nurses for Patients Admitted to Acute Care. Health Serv Insights. 2018; 11 :1178632918818836. [ PMC free article : PMC6299328 ] [ PubMed : 30618486 ]
Joyce P, Moore ZE, Christie J. Organisation of health services for preventing and treating pressure ulcers. Cochrane Database Syst Rev. 2018 Dec 09; 12 :CD012132. [ PMC free article : PMC6516850 ] [ PubMed : 30536917 ]
Cruz-Oliver DM, Abshire M, Cepeda O, Burhanna P, Johnson J, Velazquez DV, Chen J, Diab K, Christopher K, Rodin M. Adherence to Measuring What Matters: Description of an Inpatient Palliative Care Service of an Urban Teaching Hospital. J Palliat Med. 2019 Jan; 22 (1):75-79. [ PubMed : 30129814 ]
Blenke AA, van Marum RJ, Vermeulen Windsant-van den Tweel AM, Hermens WA, Derijks HJ. Deprescribing in Newly Admitted Psychogeriatric Nursing Facility Patients. Consult Pharm. 2018 Jun 01; 33 (6):331-338. [ PubMed : 29880095 ]
Rodziewicz TL, Houseman B, Hipskind JE. StatPearls [Internet]. StatPearls Publishing; Treasure Island (FL): Aug 6, 2021. Medical Error Reduction and Prevention. [ PubMed : 29763131 ]
Long M, Farion KJ, Zemek R, Voskamp D, Barrowman N, Akiki S, Reid S. A nurse-initiated jaundice management protocol improves quality of care in the paediatric emergency department. Paediatr Child Health. 2017 Aug; 22 (5):259-263. [ PMC free article : PMC5804750 ] [ PubMed : 29479230 ]
de Magalhães-Barbosa MC, Robaina JR, Prata-Barbosa A, Lopes CS. Validity of triage systems for paediatric emergency care: a systematic review. Emerg Med J. 2017 Nov; 34 (11):711-719. [ PubMed : 28978650 ]
Epstein AS, Desai AV, Bernal C, Romano D, Wan PJ, Okpako M, Anderson K, Chow K, Kramer D, Calderon C, Klimek VV, Rawlins-Duell R, Reidy DL, Goldberg JI, Cruz E, Nelson JE. Giving Voice to Patient Values Throughout Cancer: A Novel Nurse-Led Intervention. J Pain Symptom Manage. 2019 Jul; 58 (1):72-79.e2. [ PMC free article : PMC6849206 ] [ PubMed : 31034869 ]
Prado PRD, Bettencourt ARC, Lopes JL. Defining characteristics and related factors of the nursing diagnosis for ineffective breathing pattern. Rev Bras Enferm. 2019 Jan-Feb; 72 (1):221-230. [ PubMed : 30916289 ]
Brosolo V. [The nurse as a player in sexual health]. Rev Infirm. 2019 Jan; 68 (247):39-40. [ PubMed : 30910118 ]
Bookshelf ID: NBK493211 PMID: 29630263
Truglio-Londrigan M, Slyer JT, Singleton JK, Worral P. JBI Libr Syst Rev. 2012; 10(58):4633-4646.
Harmer B, Lee S, Duong TvH, Saadabadi A. StatPearls. 2022 Jan
MacKinnon K, Marcellus L, Rivers J, Gordon C, Ryan M, Butcher D. JBI Database System Rev Implement Rep. 2015 Jan; 13(1):14-26.
Wilson R, Godfrey CM, Sears K, Medves J, Ross-White A, Lambert N. JBI Database System Rev Implement Rep. 2015 Oct; 13(10):146-55.
Rodziewicz TL, Houseman B, Hipskind JE. StatPearls. 2022 Jan
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Toney-Butler TJ, Unison-Pace WJ. Nursing Admission Assessment and Examination. [Updated 2021 Aug 30]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK493211/
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StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-.
Tammy J. Toney-Butler ; Wendy J. Unison-Pace .
The initial nursing assessment, the first step in the five steps of the nursing process, involves the systematic and continuous collection of data; sorting, analyzing, and organizing that data; and the documentation and communication of the data collected. Critical thinking skills applied during the nursing process provide a decision-making framework to develop and guide a plan of care for the patient incorporating evidence-based practice concepts. This concept of precision education to tailor care based on an individual's unique cultural, spiritual, and physical needs, rather than a trial by error, one size fits all approach results in a more favorable outcome. [1] [2] [3]
The nursing assessment includes gathering information concerning the patient's individual physiological, psychological, sociological, and spiritual needs. It is the first step in the successful evaluation of a patient. Subjective and objective data collection are an integral part of this process. Part of the assessment includes data collection by obtaining vital signs such as temperature, respiratory rate, heart rate, blood pressure, and pain level using an age or condition appropriate pain scale. The assessment identifies current and future care needs of the patient by allowing the formation of a nursing diagnosis. The nurse recognizes normal and
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