Nursing Assessment

Collect objective Data

•‘collect information’

•- Vital signs

•- assess urine output, quality…

•- ABCDE

•- ECG & bloods

•- BGLs

•- bladder scan

•- Weight

•-Fluid balance (+ve or –ve?). What is the progressive total?

•-Neurological obs

•-Neurovascular obs

•-Skin assessments

•-bowel function

•- Wound assessment

•- Lung and Bowel sounds

Visual assessment

•‘Look at your patient’

•- Respiratory effort – is your patient breathing? Is their respiratory effort laboured? Shallow? Rapid?

•- Look for pallor, cyanosis

•- Look for a flushed appearance

•- Look for diaphoresis

•- LOC: Are they awake? Drowsy? Unconscious?

•-Is your patient coughing? What is the colour and quantity of the sputum?

•-Is your patient vomiting? Dry retching?

•- Can you see any pressure injuries?

•- Observe characteristics of wounds or injuries

•- Is the skin discoloured, or paper thin? Are there any skin tears?

•- Can you see any deformities?

•- Does the patient appear to be well kept?

•- Does the patient have any lines or drains? (IVCs, ICC/UWSDs, NGTs, PICCs, Infusions, IDCs…)

•- Is the patient having rigors?

Listen for clues

•- Listen for a cough (dry? Moist?)

•- Listen for a stridor, wheeze, course crackles

•- Audible bowel sounds

•- Laboured, purse lipped breathing

•- Is there evidence of dysphasia? (Impairment of production of language)

•- Is there evidence of dysphagia ( can you hear coughing or choking immediately after attempted swallowing?)

•- Flatulence

‘Palpate’

•- Skin temperature – cool or warm?

•- Is the skin clammy? Dry?

•- Assess degree of peripheral oedema

•- Is there abdominal distension?

•-Is the abdomen firm? Soft?

•- Is there a palpable bladder (urinary retention?)

‘Smell’

•- Foul smelling odour from sputum, wound beds, urine, stool, that may be indicative of an infection

•- Fruity ‘acetone’ breath (DKA)

•- Is there evidence that the patient is not attending to hygiene cares?

•- Halitosis

Enquire’

•Asking questions to obtain information, is one of the most important part of your assessment.

•for example…

•- When did the symptoms start?

•- How do you feel?

•- Do you have any pain?.....(PQRST)

•- Do you have any shortness of breath?

•- Are you feeling cold/hot? (Pts with fevers)

•- Have you been coughing? Is your cough productive? What colour is your sputum? How much sputum are you producing?

•- Are you feeling dizzy?

•- Are you sleeping well?

•- Do you have any concerns?

•- Do you understand you treatments/ investigations?

•- Do you experience any pain on urination?

•- Have you been taking all of your medications?

•- How is your appetite?

•- Have you had any falls?

NURSING ASSESSMENT