Inpatient Assessment

Perform Inpatient Assessment

Continuity of Care

• Ensuring continuity of care involves documenting treatment provided during the patient's visit and any follow-on care needed.

Nursing Assessments

• Patient Preparation: Preparing patients for medical procedures relies on the physician's diagnosis and treatment plan.

  • Specific plans and steps for preparing patients for procedures (including positioning and diagnosis-specific treatments) are detailed in other units.
  • In consultation with the physician, a plan of care is developed for the patient upon admission.

• Nursing Process: An approach to identify, diagnose, and treat human responses to health and illness, focusing on the patient's nursing needs.

  • Good communication is essential in each step.
  • When done in order and with good communication:
    • Nursing care is organized and has purpose.
    • Nursing team members share the same goals for the patient.
    • The patient feels safe and secure.

The Nursing Process Steps

• The nursing process has five steps: assessment, nursing diagnosis, planning, implementation, and evaluation.

Assessment

• Nursing assessment includes:
  • Collection and verification of data from primary (e.g., patient) and secondary sources (e.g., family, health professionals, medical record) using subjective and objective data (e.g., medical history, physical assessment, lab results).
  • Analysis of all data as a basis for developing nursing diagnoses, identifying collaborative problems, and developing a plan of individualized care.
• The nursing staff uses many sources for data collection.
• Corpsmen play a key role in assessment by making observations when providing care or having conversations with the patient.
  • They should take notes on these observations and report them to the nurse.

Nursing Diagnosis

• Nurses use the assessment information to formulate a nursing diagnosis, which is a clinical judgment about individual, family, or community responses to actual and potential health problems or life processes.
  • It describes health problems that can be treated by nursing measures and indicates actual problems and the risk of developing problems.
• Nursing diagnosis differs from medical diagnosis.
  • A medical diagnosis describes a disease or condition.
  • A nursing diagnosis is formulated based on the patient's needs because of the medical diagnosis.
    • A person may have many nursing diagnoses for one medical diagnosis.
• Considerations when developing a nursing diagnosis:
  • Physical needs
  • Emotional needs
  • Social needs
  • Spiritual needs

Planning

• Involves setting patient-centered goals and expected outcomes, and plans nursing interventions.
  • Nursing actions are chosen to assist the patient in meeting goals.
  • The patient, family, and health care team contribute to the care plan.
  • Diagnoses are prioritized to meet the patient's immediate needs.
  • Setting goals (short and long-term) and expected outcomes:
    • Must be patient-centered, singular, observable, measurable, time-limited, mutual, and realistic.
    • Set at the person's highest level of wellbeing (e.g., patient will maintain blood sugar within the therapeutic range).
  • Interventions are selected to assist the patient to reach goals and expected outcomes.

Implementation

• Performing or carrying out the nursing measures using interventions developed during planning.
  • Care is given.
  • Report and record observations and care.

Evaluation

• Crucial to determine whether the patient's condition or well-being has improved after the application of the nursing process.
  • Evaluative measures determine if expected outcomes were met, not if nursing interventions were completed.
  • Assess the patient's response to nursing actions and evaluate patient progress.
  • Modify nursing diagnosis, goals, and plan of care as needed.
  • The nursing process is a continuous cycle; problems and special needs must be identified.

Performing Inpatient Assessments

• This section provides instructions on how to perform a quick head-to-toe inpatient assessment.
• The nature and complexity of a physical examination depends on the patient's condition at the time of your encounter.
• Fast and accurate assessment requires readiness and repetition. Organizing and prioritizing examination steps allows for gathering pertinent patient information quickly and identifying abnormalities before they turn into crises.
• The physical examination begins upon encountering a patient, whether during admission, a home/clinic visit, or during a shift.
  • Physical examinations must be performed at regular intervals to assess expected and unexpected changes in a patient's condition to provide quality ongoing health care.

Pointers for Successful Assessment

• Review the patient's health history for important medical, surgical, and family details before starting the examination.
• If the patient has a chief complaint, gather information about it and any new problems/symptoms that may have developed since the history was taken.
• Ensure proper equipment to perform the physical examination comfortably and completely.
• Ensure an appropriate environment (e.g., warm room, sufficient lighting).
  • Ensure patient privacy by closing the door or drawing the curtain.
  • Ask visitors/other health care providers to leave, or delay the examination, unless the patient wants them present.
• Record findings (both normal and abnormal) in note form as you go along.

Inpatient Assessment Steps

• Assess the patient informally at every opportunity to catch changes or problems as early as possible.
  • Be aware of the patient's condition any time you are in their presence.
  • Steps include:
    • General Appearance: demeanor, facial expression, and gait
    • General Impression: "How are you feeling today?" - note response; respiratory effort
    • Mental Status: A&O x3 [time, person, place]/responsiveness/level of consciousness
    • Chief complaint/apparent life-threats or additional complaints since admission
    • Pain: Collect AND/OR verify the history of present illness (OPQRS)-[worse or better since admission]
    • Allergy: Verify by asking patient allergy information; verify against the chart
    • Medications: Review patient's current and new medications; verify against the chart
    • Assess Breathing: adequate ventilation and appropriate oxygen therapy [verify provider order]
    • Assess pulse bilaterally (strength) and skin (color, temp, and condition), capillary refill
    • Check patient's eyes for PERRL
    • Cardiovascular: Auscultate heart, check bilateral peripheral pulses, assess for JVD, and note complaints of chest pain
    • Respiratory: Auscultate lung sounds, observe chest wall motion, and note complaints of difficulty breathing
    • Gastrointestinal: Inspect, auscultate, and palpate all four quadrants of the abdomen- check for excretion [last bowel movement] Record and/or verify last oral intake
    • Urinary: Ask patient when last void and any difficulties with voiding
    • Musculoskeletal: Inspect and palpate limbs, note any deformity or asymmetry, assess ROM and strength of extremities
    • Integumentary: Inspect and palpate skin anterior and posterior, note any edema, dry or oily skin, lesions, contusion, and/or abrasions.
    • Psychological: Obtain or verify a history of any conditions
    • Obtain Vital Signs and Conduct Intake and Output Assessment
    • Document assessment and report abnormal findings to the provider

Documentation

• Ensure that all findings while performing the physical assessment are documented on the SF 510 and DD Form 792 as applicable.
  • Any abnormal findings must be documented and addressed to the nurse to verify and notify the provider.
• While the forms for Inpatient Care may differ, the concepts and principles of documenting are the same as those for an Outpatient Procedure.