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Definition/Introduction
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]
Definition/Introduction
Issues of Concern
Clinical Significance
What information should be obtained as part of a comprehensive health history?
When interviewing a patient what is it that the healthcare professional can observe?
What question would you ask to assess the patient’s level of comfort?
Which elements are included in the functional assessment of a patient’s nutritional health?
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
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.[6][7][8][9]
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 tư vấn
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
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 toàn thân weight, need for nutritional consultation based on body toàn thân 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
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
Initial
Assessment[10][11][12]
Steps in Evaluating a New Patient
Record chief complaint and history
Perform physical examination
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
Which provides the diagnosis most often: history, physical, or diagnostic tests?
History: 70%
Physical: 15% to 20%
Diagnostic tests: 10% to 15%
History Taking Techniques
Record chief complaint
History of the present illness, presence of pain
P-Q.-R-S-T Tool to Evaluate Pain
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?
S-A-M-P-L-E
S: Signs and symptoms
A: Allergies
M: Medications
P: Past medical history
L: Last meal or oral intake
E: Events before the acute situation
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
Restlessness or pacing
Groaning or moaning
Crying
Gasping or grunting
Nausea or
vomiting
Diaphoresis
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 toàn thân
Unable to speak or open eyes
Decreased interest in activities, social gatherings, or old routines
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
Ambulatory aids
Environmental concerns, home safety
Domestic and family violence risk, human trafficking risks, elder or child abuse risk
Fall risk
Suicidal ideation (initiate suicide precautions as directed by institutional policy)
Therapeutic Communication Techniques Used to Take a Good History
Multiple strategies are employed that will include:
Active, attentive listening
Reflection, sharing observations
Empathy
Share hope
Share humor
Touch
Therapeutic silence
Provide information
Clarification
Focusing
Paraphrasing
Asking relevant questions
Summarizing
Self-disclosure
Confrontation
What are examples?
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 tư vấn, 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, tư vấn, 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
Cultural Assessment
The
cultural competency assessment will identify factors that may impede the implementation of nursing diagnosis and care. Information obtained should include:
Ethnic origin, languages spoken, and need for an interpreter
Primary language preferred for written and verbal instructions
Support system, decision makers
Living arrangements
Religious practices
Emotional responses
Special food
requirements, dietary considerations
Cultural customs or taboos such as unwanted touching or eye contact
Physical Examination Techniques
Initial evaluation or the general survey may include:
Stature
Overall health status
Body habitus
Personal hygiene, grooming
Skin condition such as signs of breakdown or chronic wounds
Breath and body toàn thân odor
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 toàn thân mass index (BMI) is calculable for dosing weights and nutritional guidelines
Secondary
Assessment
Cardiovascular
Pulmonary
Gastrointestinal
Musculoskeletal
Neurological
Genitourinary/Pelvic
Integumentary
Mental status and behavioral
Techniques
Inspection
Look at all areas of the skin, including those under clothing or gowns
Ensure patient is undressed, allowing for privacy, uncover
one body toàn thân part at a time if possible
Lighting should be bright
Be alert for any malodors from the body toàn thân 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
Grade any edema present
Document pertinent normal
and abnormal findings
Palpation
Texture
Size
Consistency
Crepitus
Any masses
Turgor
Tenderness
Temperature and moisture (warm, moist or cool, and dry)
Distention
Tactile fremitus
Percussion
Good hand and finger technique
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
Auscultation
Listening to body toàn thân 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
What are important things to remember about the physical exam?
Physical exam length can vary depending on complexity
Physical exam extends from passive observation to hands-on
Be systematic and thorough
Ensure privacy and comfort
Warm hands for patient comfort
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
Diagnostic Studies
Driven by findings on
the history and physical examination; options include:
Other diagnostic studies (ECG, EEG, lumbar puncture, etc.,)
Discharge Planning
Document mode of transport
Who is accompanying the patient?
Transfer forms/EMTALA
considerations
Functional status
Financial considerations
Discharge medications and instructions
Follow up information, referrals, hotline numbers, shelter information
Barriers to learning
Document verbalization that discharge instructions were understood by caregiver or surrogate
Provide translators and language appropriate discharge instructions or paperwork
Clinical Significance
Often 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
Situation
Background
Assessment
Recommendation
Assessment Tools
Activities of daily living scale
Cough assessment
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
CAGE assessment/CIWA scoring
Morse Fall Risk
Standard vital
sign flow charts for different age groups
NIH Stroke Scale (NIHSS)
Dysphagia Screen
4AT Assessment for Delirium
Equipment
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
References
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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 không lấy phí article: PMC6319242] [PubMed: 31011096]
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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 trang chủ 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 không lấy phí 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 không lấy phí article: PMC6516850] [PubMed: 30536917]
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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]
(FL): May 1, 2022. 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 không lấy phí article: PMC5804750] [PubMed: 29479230]
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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]
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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 không lấy phí article: PMC6849206]
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What information should be obtained as part of a comprehensive health history?
A comprehensive health assessment usually begins with a health history, which includes information about the patient’s past illnesses or injuries (including childhood illnesses and immunizations), hospitalizations, surgeries, allergies and chronic illnesses.
When interviewing a patient what is it that the healthcare professional can observe?
In this instance, observation includes using all five senses to gather cues. Nurses begin assessing patients from the moment they meet them, noting their appearance, posture, gait, verbal communication, nonverbal communication, and behaviors.
What question would you ask to assess the patient’s level of comfort?
Questions such as “How are you feeling?” “Are you comfortable now?” “Do you feel well enough to talk now?”are helpful.
Which elements are included in the functional assessment of a patient’s nutritional health?
The assessment of nutritional status includes, in addition to dietary intake, indicators of nutrition-related health status, such as anthropometric measurements, hematological and biochemical tests, clinical signs of deficiencies, and risk factors for diseases associated with diet (e.g., overweight).
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