CorrectCare

Assessment: The Key to Your Success as a Nurse
By Susan Laffan, RN, CCHP-A

Professional standards of nursing  call for nurses to identify patients’ health needs, set goals for treatment and care, and be a patient advocate. To accomplish these things, we must be able to assess our patients completely. Think of nursing assessment as the building blocks of patient care. Just as important, though less often discussed, is reassessment.

To define terms, nursing assessment is the gathering of information about a patient’s physiological, psychological, sociological and spiritual status. It is the first stage of the nursing process that identifies the patient’s problems and needs.

More specifically, the purpose of assessment is to obtain baseline data on the patient’s physical and mental status; to supplement, confirm or question data obtained in the nursing history; to obtain data that will help to establish a nursing diagnosis and plan patient care; and to evaluate whether the nursing interventions were appropriate in meeting the patient’s identified needs.

Assessment involves both subjective and objective data. Subjective data is the information the patient tells you, such as “I have pain.” Objective data is the information you observe or are able to measure, such as vital signs and, for example, whether the patient is comfortable or unable to lie still.

A nursing assessment includes a physical exam, observation or measurement of signs and a review of symptoms expressed by the patient. (See box at right for the components of a thorough assessment.)

A word about vital signs: These are an essential assessment tool, yet all too often a full set of vital signs is not obtained. It is important to obtain and assess all vital signs, to include blood pressure, pulse, temperature, respirations and pulse oximetry readings.

Reassess and Document
Some nurses are very good at the initial assessment of the patient yet fail to follow up with reassessment. Others neglect to properly document their findings. For every intervention a nurse provides, there should be a reassessment to gauge the patient’s response to the intervention and documentation of that response.

For example, if the nurse provided pain medication, then the patient’s pain scale must be reassessed. If the medication has given relief from pain, that must be documented. If it gave only partial or no relief, that also must be documented, and it is then the nurse’s obligation as a patient advocate to notify the physician for other intervention.

Returning to the importance of vital signs, an example of proper reassessment of a patient with an elevated temperature is to also measure and record the pulse, because an increased heart rate can be one body response to a fever.

Nursing Care Plans
A nursing care plan can be initiated by any registered nurse who provides care to a patient. The plan must be thorough and easy to understand. After all, it will guide not only the nurse who initiates the plan, but also all of the other nurses who care for that patient.

The nursing care plan includes assessments and treatments based on the medical diagnosis or orders from the physician. The plan should be updated regularly by all RNs who provide care to that patient. As treatment and interventions occur, the plan may need to be adapted to meet the current needs identified. These needs may include patient teaching, continued assessments and treatments, and follow-up care.

It may help to use the following concepts when evaluating assessment findings and planning for care:

• Stable: Health or disease processes are in a steady state and likely to remain so; provision of correct treatment and care regimes should continue.

• Unstable: Disease process is fluctuating, resulting in a variable health state; this requires frequent or regular intervention and/or treatment.

• Predictable: Patient response to internal and/or external triggers or interventions can be anticipated with some certainty, through established interventions and regularly reviewed care plans. If the expected outcome is not reached, the plan must be reassessed and intervention should reflect the changes in the plan.

• Unpredictable: Patient response to triggers or interventions cannot be anticipated with any certainty. Continuous assessment, care planning, intervention and review are required.

Case Studies
In reviewing cases—whether for quality improvement purposes or for lawyers—the item most often lacking is the reassessment of the patient. It could be argued that if the nurse did not reassess the patient after interventions were provided, there’s no way to know if the patient benefited from the intervention or if the patient’s needs were met.

In extreme cases, a failure to reassess could lead to life threatening events or even death. A real-life example is a patient in withdrawal from heroin with the symptoms of persistent nausea, vomiting and diarrhea for an extended period of seven days. Yes, the nurses provided the intervention of an antiemetic drug, but the symptoms continued. There was no documentation after any of the six doses that the patient either responded or, in this case, did not respond. This patient went into cardiac arrest and subsequently died as a result of severe dehydration and lactic acidosis.

Another case involved a patient with a finger wound. Dressings were changed daily, yet there was no documentation of the wound status with regard to signs of infection, such as redness, swelling or increased pain. You guessed it: The wound was infected, and after 10 days it became so severe that the finger had to be partially amputated.

Put It in Writing
Documentation is essential to our practice as nurses, both to ensure that we understand what is going on with the patient and to prove that we do. Remember the saying, “If it isn’t documented, you did not do it.”

Documentation can be done in many different ways, using different models and custom flowcharts, whether paper or electronic. Regardless of method, all findings, interventions, reassessments and patient responses must be documented. And every area on that flowchart must be filled out correctly.

 — About the author: Susan Laffan, RN, CCHP-A, is the principal of Specialized Medical Consultants, Toms River, NJ.

[This article first appeared in the Spring 2007 issue of CorrectCare.]