NUR 643E Week 8 Discussion initial assessment techniques

DQ1 You walk into a patient’s room and find him unconscious because he does not greet you when you walk in. What are some of your initial assessment techniques that need to be employed and why?

DQ2 You just reviewed the morning laboratory report for a patient in critical care. You noted that the potassium level is 6.5 mEq/L. What are areas you need to be assessing the patient to monitor for complications from hyperkalemia? Explain your approach in a head to toe assessment.

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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)

Go to:

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

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

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

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NUR 643E Week 8 Discussion initial assessment techniques