Definition/IntroductionThe 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] Show
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.[4][5] Nursing Process
Issues of ConcernThe 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.[6][7][8][9] This includes documenting:
The nurse should strive to complete:
Summary Nursing Admission Assessment
Physical Exam
Initial Assessment[10][11][12] Steps in Evaluating a New Patient
Which provides the diagnosis most often: history, physical, or diagnostic tests?
History Taking Techniques Record chief complaint History of the present illness, presence of pain P-Q-R-S-T Tool to Evaluate Pain
S-A-M-P-L-E
Pain Assessment Pain, or the fifth vital sign, is a crucial component in providing the appropriate care to the patient. Pain assessment may be subjective and difficult to measure. Pain is anything the patient or client states that it is to them. As nurses, you should be aware of the many factors that can influence the patient's pain. Systematic pain assessment, measurement, and reassessment enhance the ability to keep the patient comfortable. Pain scales that are age appropriate assist in the concise measurement and communication of pain among providers. Improvement of communication regarding pain assessment and reassessment during admission and discharge processes facilitate pain management, thus enhancing overall function and quality of life in a trickle-down fashion. According to one performance and improvement outpatient project in 2017, areas for improvement in pain reassessment policies and procedures were identified in a clinic setting. The study concluded compliance rates for the 30-minute time requirement outlined in the clinic policy for pain reassessment were found to be low. Heavy patient load, staff memory rather than documentation, and a lack of standardized procedures in the electronic health record (EHR) design played a role in low compliance with the reassessment of pain. Barriers to pain assessment and reassessment are important benchmarks in quality improvement projects. Key performance indicators (KPIs) to improve pain management goals and overall patient satisfaction, balanced with the challenges of an opioid crisis and oversedation risks, all play a role in future research studies and quality of care projects. Recognition of indicators of pain and comprehensive knowledge in pain assessment will guide care and pain management protocols. Indicators of Pain
Psychosocial Assessment The primary consideration is the health and emotional needs of the patient. Assessment of cognitive function, checking for hallucinations and delusions, evaluating concentration levels, and inquiring into interests and level of activity constitute a mental or emotional health assessment. Asking about how the client feels and their response to those feelings is part of a psychological assessment. Are they agitated, irritable, speaking in loud vocal tones, demanding, depressed, suicidal, unable to talk, have a flat affect, crying, overwhelmed, or are there any signs of substance abuse? The psychological examination may include perceptions, whether justifiable or not, on the part of the patient or client. Religion and cultural beliefs are critical areas to consider. Screening for delirium is essential because symptoms are often subtle and easily overlooked, or explained away as fatigue or depression. Safety Assessment
Therapeutic Communication Techniques Used to Take a Good History Multiple strategies are employed that will include:
What are examples?
Cultural Assessment The cultural competency assessment will identify factors that may impede the implementation of nursing diagnosis and care. Information obtained should include:
Physical Examination Techniques Initial evaluation or the general survey may include:
Secondary Assessment
Techniques Inspection
Palpation
Percussion
Auscultation
What are important things to remember about the physical exam?
Diagnostic Studies Driven by findings on the history and physical examination; options include:
Discharge Planning
Clinical SignificanceOften the initial history and physical examination lead to the identification of life- or limb-threatening conditions that can be stabilized promptly, ensuring better patient outcomes. The sooner the patient is correctly assessed, the more likely a life-altering condition is recognizable, nursing diagnosis formulated, appropriate intervention or treatment initiated, and stabilizing care rendered. Physiological abnormalities manifested by changes in vital signs and level of consciousness often provide early warning signs that patient condition is deteriorating; thus, requiring prompt intervention to forego an adverse outcome, decreasing morbidity and mortality risk. In the fast-paced, resource-challenged healthcare environment today, thorough assessment can pose a challenge for the healthcare provider but is essential to safe, quality care. The importance of a head-to-toe assessment, critical thinking skills guided by research, and therapeutic communication are the mainstays of safe practice. [13][14][15] Assessment findings that include current vital signs, lab values, changes in condition such as decreased urine output, cardiac rhythm, pain level, and mental status, as well as pertinent medical history with recommendations for care, are communicated to the provider by the nurse. Communicating in a concise, efficient manner in rapidly changing situations and deteriorating patient conditions can promote quick solutions during difficult circumstances. Healthcare providers communicate and share in the decision-making process. The SBAR model facilitates this communication between members of the healthcare team and bridges the gap between a narrative, descriptive approach and one armed with exact details. Communication using the SBAR Model
Assessment Tools
Equipment
References1.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] 2.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] 3.Palmer RM. The Acute Care for Elders Unit Model of Care. Geriatrics (Basel). 2018 Sep 11;3(3) [PMC free article: PMC6319242] [PubMed: 31011096] 4.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] 5.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] 6.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] 7.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] 8.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] 9.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] 10.Rodziewicz TL, Houseman B, Hipskind JE. StatPearls [Internet]. StatPearls Publishing; Treasure Island (FL): Aug 6, 2021. Medical Error Reduction and Prevention. [PubMed: 29763131] 11.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] 12.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] 13.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] 14.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] 15.Brosolo V. [The nurse as a player in sexual health]. Rev Infirm. 2019 Jan;68(247):39-40. [PubMed: 30910118] Which of the following would the nurse identify as the major electrolyte responsible for determining the concentration of the extracellular fluid?Sodium, the most prominent electrolyte 'solute' in extracellular fluid, is used to monitor extracellular osmolarity.
Which clinical manifestations would lead the nurse to suspect that a client is experiencing Hypermagnesemia?Hypermagnesemia is manifested by hot, flushed skin and diaphoresis. The client also may exhibit hypotension, lethargy, drowsiness, and absent deep tendon reflexes. Muscle pain and acute rhabdomyolysis are indicative of hypophosphatemia. Soft-tissue calcification and hyperreflexia are indicative of hyperphosphatemia.
What assessment finding should the nurse identify in a client with fluid volume excess?Evaluation. Which patient is at most risk for fluid volume deficit?Cardiac and older patients are often susceptible to fluid volume deficit and dehydration due to minor changes in fluid volume. They also are susceptible to the development of pulmonary edema. 12.
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