In-Depth Notes on Assessment of Hospitalized Patients

Common Assessment of Hospitalized Patients

• Admission Assessment

  • Performed upon patient admission; comprehensive overview of health status.
  • Focuses on physical, emotional, and mental aspects across all body systems, taking environmental, cultural, and social issues into account.
  • Addresses urgent needs first, then conducts a full assessment.
  • Risks for falls and skin breakdown due to hospitalization are included.

• Shift Assessment

  • Includes shorter evaluations done at the start of each shift, focused on key risk areas: heart, lungs, abdomen, and includes patient orientation.
  • Focused assessment relates to anticipated problems specific to the patient, particularly before transfers.

Shift Change Reports

• Comprises crucial information including:
  • History and physical (H&P) from the chart
  • Summary of events since admission
  • Laboratory and radiological reports
  • Prior assessment details
  • Conducted in patient rooms with family present, if fitting
  • Utilizes I-PASS format for streamlined communication.

I-PASS Reporting

• I-PASS mnemonic
  • Illness severity
  • Patient information
  • Action list
  • Situational awareness and contingency plans
  • Synthesis by receiver

Rapid and Routine Assessment Preparation

• Takes less than 1 minute and involves the following steps:
  • Hand hygiene and isolation precaution note
  • Enter room, introduce self and verify patient identity using ID band
  • Ensure call bell accessibility and bed position.

Focused Assessment

• Integrated into the Shift Assessment and can take between 2 to 20 minutes.
• Critical thinking is essential to determine the necessary information to collect and identify any trends in the patient’s status.

Typical Assessment Components

• Level of Consciousness (LOC): (A & O x3 or x4)
• Vital Signs (V/S): Temperature, Pulse, Respiration, Blood pressure, O2 saturation
• Pain Assessment
• Skin assessment: turgor, intactness, wounds
• Cardiovascular: Heart sounds S1, S2, rate, rhythm
• Respiratory effort
• Abdominal and GI system assessment
• Musculoskeletal symmetry and function
• Assess for drains, catheters, tubes, and IVs.

General Survey and Specific Assessments

• Assesses orientation (A & O x4), communication clarity, memory integrity, behavior appropriateness.
• Urgent Assessments Indicators:
  • Extreme anxiety, acute distress, pallor or cyanosis, change in mental status.
  • Call for Rapid Response Team (RRT) if vitals show red flags.

Adapting Physical Assessments

Skin

• Check for temperature, moisture, lesions, and assess for pressure ulcers.

Lungs & Respiratory System

• Assess respiratory effort, skin color, and auscultate lung sounds both posteriorly and anteriorly.

Heart & Vascular System

• Evaluate heart rhythm and pulse locations; check capillary refill and signs of peripheral edema.

Abdomen & GI Assessment

• Inspect for distention, bowel sounds, and check for nausea, vomiting, or diarrhea.

Urinary Catheters

• Monitor urine output and assess characteristics like color and clarity.

Musculoskeletal Assessment

• Observe symmetry, strength, and coordination, assess mobility aids.

Clinical Judgment after Assessment

• Notice abnormal findings (e.g., crackles, edema), interpret data, document findings, and implement nursing interventions as necessary.

Documentation Formats

• Utilizes various documentation styles emphasizing continuity of care, including SOAP notes and electronic medical records (EMR).

HIPAA Regulations

• Protects patient confidentiality concerning all written and verbal communications.
• Ensures only authorized personnel access patient information and maintain secure records and electronic data.

American Hospital Association Terminology

• Understanding patient condition:
  • Stable: Vital signs within normal limits (WNL).
  • Fair: Conscious but uncomfortable.
  • Serious: Unstable, acutely ill.
  • Critical: Unconscious with abnormal vital signs.

Geriatric Assessment

• Focus on confusion, urinary incontinence, and falls, considering risks and necessary safeguards.
• Evaluate vital signs, and assess orientation and strength.

Health Teaching Considerations

• Provide tailored education to patients based on individual health risks and age-related needs.

Case Studies for Practical Application

• Apply assessment principles to hypothetical patients to refine analytical skills and judgment in nursing practices.