Question

Demonstrate ability to assess the health status of assigned patients / clients / residents.

Answer 1

Assessment is a key component of nursing practice, required for planning and provision of patient and family centred care.

Assessment can be done at the time of admission, which is the detailed health assessment and daily assessment as well as assess during each shift.

Admission assessments include general condition, physical assessment , social history and family history assessments and vital signs.  

Assessment if assigned patients is carried out during each shift. It includes :

• Airway: noises, secretions, cough, any artificial airways
• Breathing: bilateral air entry and movement, breath sounds, respiratory rate, rhythm, work of breathing.
• Circulation: pulses (location, rate, rhythm and strength); temperature (peripheral and central), skin colour and moisture, skin turgor, capillary refill time (central and Peripheral); skin, lip, oral mucosa and nail bed colour. ECG rate and rhythm if monitored.
• Observation of vital signs including Pain: use FLACC, Wong Baker Faces, numeric scale, Neonatal Pain assessment tool, Comfort B scale as appropriate to the age group.
• Skin: Colour, turgor, lesions, bruising, wounds, pressure injuries.
• Hydration/Nutrition: Assess hydration and nutrition status and check feeding type- oral, nasogastric, gastrostomy, jejunal, fasting, and breast fed, type of diet, IV fluids.
• Output: Assess Bowel and Bladder routine(s), incontinence management urine output, bowels, drains and total losses. Review fluid balance activity
  Blood sugar levels as clinically indicated.
• Risk assessment includes, risk for fall, pressure ulcers and so on.

If required, focussed assess of certain system can be done in each shift.