Nursing Assessment

Flowchart nodes

• 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