NUR 643E Week 8 Assignment Initial Assessment Techniques

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.

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 abnormal patient physiology and helps prioritize interventions and care.

Nursing Process

• 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)

Issues of Concern

The function of the initial nursing assessment is to identify the assessment parameters and responsibilities needed to plan and deliver appropriate, individualized care to the patient.

This includes documenting:

• Appropriate level of care to meet the client’s or patient’s needs in a linguistically appropriate, culturally competent manner
• Evaluating response to care
• Community support
• Assessment and reassessment once admitted
• Safe plan of discharge

The nurse should strive to complete:

• 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

Summary Nursing Admission Assessment

1. Documentation: Name, medical record number, age, date, time, probable medical diagnosis, chief complaint, the source of information (two patient identifiers)
2. Past medical history: Prior hospitalizations and major illnesses and surgeries
3. Assess pain: Location, severity, and use of a pain scale
4. 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
5. 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
6. 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
7. Rights: Orient patient, caregivers, and family to location, rights, and responsibilities; goal of admission and discharge goal
8. Activities: Check daily activity limits and need for mobility aids
9. Falls: Assess Morse Fall Risk and initiate fall precautions as dictated by institutional policy
10. Psychosocial: Evaluate need for a sitter or video monitoring, any signs of agitation, restlessness, hallucinations, depression, suicidal ideations, or substance abuse
11. Nutritional: Appetite, changes in body weight, need for nutritional consultation based on body mass index (BMI) calculated from measured height and weight on admission
12. Vital signs: Temperature recorded in Celsius, heart rate, respiratory rate, blood pressure, pain level on admission, oxygen saturation
13. Any handoff information from other departments

Physical Exam

• 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