Medical-Surgical Nursing A+ GRADE

Assessment is the first step in determining the condition of the patient’s health and their immediate and long-term needs. The nursing assessment of patients on admission to hospital or on attendance at clinics is key to clinical decision-making and to planning patient care that takes account of the individual patients’ needs and circumstances. Nurses have responsibility for carrying out the initial and ongoing patient assessments, for initiating interventions that take patients’ needs into consideration and for evaluating the effectiveness of these interventions. The nursing assessment is one component within a larger, multidisciplinary team assessment during which the patient is assessed by different healthcare professionals as part of the care pathway and patient referral process. A multifactorial assessment of the older person for falls, for example, can involve the nurse, doctor, physiotherapist, occupational therapist, optician and other healthcare professionals working in specialist areas of practice such as cardiac assessment. As a member of the multidisciplinary team, the nurse often plays a key role in coordinating the patient assessment and ensuring that appropriate referrals are made and followed up. The principles of nursing assessment presented in this chapter are in line with the national guidelines from the professional nursing board in Ireland, An Bord Altranais, and in the UK the Nursing and Midwifery Council (NMC). The principles need to be read in conjunction with local policies and procedures for the nursing assessment, which are usually set by the hospital or healthcare employer. At ward or unit level, more specific assessment procedures may apply; for example, cerebrovascular or stroke units may include an assessment of swallowing and mood as part of the assessment of a patient newly diagnosed with a cerebrovascular accident – a stroke. The purpose of nursing assessment Assessment is the first stage in the nursing process and is key to developing a care plan that is tailored to a patient’s individual needs (Figure 1.1). The purpose of assessment is to achieve the following: • Obtain baseline data and track changes. On admission to hospital or on a first visit to the clinic, it is important to carry out a comprehensive assessment of the patient to establish a set of baseline data against which subsequent assessments can be compared and any changes indicating a deterioration or improvement in the patient’s condition tracked. • Early recognition of the critically ill or deteriorating patient. Identifying patients who are ‘at risk’ is key to initiating a rapid response from the medical emergency or rapid response team. ‘Track and Trigger’ (e.g. Alert® and other early warning systems) incorporate objective physiological and subjective criteria that can be used to support the nurse’s decision about when to call the medical team for help and avert more serious patient emergencies (National Institute for Health and Clinical Excellence [NICE], 2007). If a Track and Trigger system has not been set up in the hospital, a nurse who is concerned about a patient should take urgent action and notify the medical team. • Risk assessment. Assessment is the first step in preventing complications, the aim being to identify patients who are ‘at risk’ of developing complications associated with their healthcare problem, hospitalisation and reduced mobility. Key areas for risk assessment include pressure ulcers, infection, falls and constipation. Local hospital policy may include risk assessment tools as part of the admission procedure, for example the Braden, Waterlow and Norton scores to identify patients at risk of pressure ulcers and to activate an action plan and interventions to prevent pressure ulcers developing. • Screening for health problems. Nursing assessment provides an ideal opportunity for health promotion and for screening patients for risk factors associated with obesity, cancer, cardiovascular disease, diabetes mellitus and other major Irish and UK health problems. It also provides the opportunity to screen for specific problems such as emotional distress or organisms important in infection control (e.g. methicillin-resistant Staphylococcus aureus [MRSA] and vancomycin-resistant Enterococcus [VRE]). Part 1 Common Principles Underlying Medical and Surgical Nursing P