When All Else Fails... Assess Your Patient!

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Pity...our patients don't arrive on the clinical unit with their priority diagnoses imprinted on their foreheads. Sure would make our lives easier wouldn't it? Have you ever wondered why you struggle to come up with the right diagnoses, or why your care plans bleed red when returned by your instructor? I can tell you! You didn't assess your patient adequately.

by Episteme Episteme

Specializes in Education, research, neuro. Has 43 years experience.

When All Else Fails... Assess Your Patient!

Real nursing is not what happened at the ends of your fingers the last time you cared for a patient. No. Genuinely professional nursing is what went on between your ears when you planned the care, gave it, and evaluated its effects. Professional nursing is a disciplined thought process requiring diagnosis of problems preventing patients from achieving their best baseline health. And THAT'S the rub, right? You just can't quite find the right diagnosis to explain your plan of care to your instructor. You just can't find the right combination of words no matter how many times you thumb through your list of "NANDA's".

The reason this happens is because students (and sometimes registered nurses) do not collect full and abundant assessment data on their patients. Sure, you probably noted the most remarkable things about your patient's conditions, the most obvious deformities or deficiencies... but did you assess your patient? If you're confused... the answer is NO.

Let's describe what rich, abundant assessment looks like. First of all, it's systematic. Many nurses assess from head to toe. Others have a mental list of priority human needs that they click through as they interview and examine their patients. It doesn't matter what the system is, as long as you have one.

The first step in your assessment is to just look at your patient. Are they looking back at you? Are they tracking you visually as you step into the room. Are they interacting with you? Or are they in some distress that is preventing them from engaging you? Without touching or speaking you've set the stage for thorough patient assessment.

Next, you must know your patient's most recent vital signs and the trends they've shown over the last hours. Vital signs are called "vital" for a reason! Having done those two things... you're ready to begin your systematic assessment.

Oxygen: Ask Yourself...

Is my patient breathing comfortably? Is he breathing comfortably only in the bed? How about when he ambulates to the bathroom? Listen to your patient's lungs. What is the underlying breath sound and are there sounds that don't belong? What information about your patient's cardiopulmonary status can I find in the patient's records. When was his last chest film and how was it interpreted? What were your patient's most recent arterial blood gasses? Does he have a history of pulmonary problems or is he on any pulmonary related medication? Next, ask yourself...

Is my patient's heart OK? Is it moving blood to the rest of his body and doing so with good cardiac reserve? Listen to his heart. Feel the pulses on all extremities, look at capillary refill. Everyone in the hospital has had an EKG, what was the reading on your patient's? Are there lab values that inform you about your patient's heart? Toponins? BNP? Look again at your patient. Are you seeing any edema? Where? Legs? Sacrum? Does he have jugular veigh distention as well? Now it's time to check out...

Heme studies! Does the patient have enough RBC's with enough hemoglobin to carry oxygen to his tissues? What's his hematocrit and hemoglobin? If it is low, is it nutritional? (You might have to check out some additional labs on this one...) or is it blood loss anemia? If the latter, where is he bleeding? What do I need to assess to find out? So far so good... but the blood has to get to the tissues.

Are the patient's arteries and veins competent and conveying blood to and from the tissues? Are your patient's feet warm? Equally so? Does he/she have any pain when walking (claudications.) Are his feet/ankles/legs discolored or do they show any signs of venous stasis?

Fluid and Electrolytes

Do you know what your patient's basic metabolic panel showed? If not... go get that data and think deeply about what it tells you! Is your patient drinking and voiding adequate amounts? If not... are we giving fluids by some other route? Figure out...

If your patient is dry... why? Does this patient have functioning kidneys? If not, why not? And what do you know about the patient metabolically (as in that BMP mentioned above). Then determine if...

there is any weird source of body fluid loss. (Vomiting? Diarrhea? Diaphoresis? Fistulas? Oh, and if he's on NG suction... how much is getting pulled off and how fast?

Nutrition

What's your patient's height/weight/BMI?

Are they eating the right things? You don't need to do a food diary immediately... but IS you patient eating? If not, why not? Does you patient have teeth?

If you have any suspicion of nutritional deficiency, track down that laboratory evidence so you can semi-quantify it.

If your patient is on any special enteral diet (tube feeds) or parenteral feeding (TPN) figure out how many calories, grams of protein, carbohydrate and fats he/she is getting.

Elimination: Basically this is about pee and poo

Is your patient producing both without difficulty? When was his/her last bowel movement? And is he/she on stool softeners? Is your patient on any medication (and there are tons of them!) that can interfere with pee and poo?

Rest/Restoration

Is your patient in pain? Why and where? How much of the time? Is it chronic or acute?

Make your patient describe the pain AND QUANTIFY ITS SEVERITY on a pain scale. What analgesics is the patient taking? When was the most recent dose taken and when can the next be given? Does your patient have any side-effects of related to the analgesic?

(constipation, respiratory depression, dizziness, etc.) Are the drugs offering relief?

Is your patient sleeping? Is he/she awake during the day and asleep at night? If no, why not? Semi-quantify how much sleep the patient is getting. Is the patient on medication to help him/her sleep? Are they using it? Does it work?

Mobility

Does your patient walk? Get up to a chair? How well does he/she toerate this?

Does the patient use assistive devices?

If he/she is not moving normally why not? If pain... see above. If neuro... see below.

If your patient doesn't move from bed to chair to upright and walking very much, please look for the consequences of immobility. Swollen calves, skin breakdown, atelectasis.

Other stuff that keeps your patient alive

Clotting: Does the patient have any problems with either bleeding or thrombus formation? Is he/she on an anticoagulant? What are the most recent coagulation studies? What is your patient's platelet count?

Immunity and Infection: What is your patient's white count? Is he/she running a fever? Does your patient have any predisposition to getting infected? (Wind: lungs. Water: UTI. Wounds.) Is the patient on any antibiotics? If so, do you know where the infection is?

Neuro: Is your patient AAOx4? If not, describe the deficiency. Does the patient interact with you and follow you with his eyes and are his pupils PERRL? Does he have one side that works better than the other? Does he have equal strenght on both sides with grips and dorsi-plantar flexion? Can they hold their legs off the bed (one at a time) and does he have any dirft (Holding arms out with eyes closed, one arm drifts down.)

Well... that's a good start. Will you make all these observations immediately? No. And that's OK. But it is YOUR JOB to have all of this information at the end of your 8-12 hour clinical day and before you go home.

When you are unsure about how to express your patient's priority problem... when you're scratching your head and thinking in circles... it's almost always because you don't know enough about your patient. You MUST assess you patient before you can think rationally about his care.

RN. 43 year(s) of experience in Education, research, neuro

2 Articles   182 Posts

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23 Comment(s)

Esme12, ASN, BSN, RN

Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma. Has 42 years experience. 4 Articles; 20,908 Posts

I so wish students were able to NOT focus on NANDA..."THE LIST" and focus instead on their patient assessment.

What disease does your patient have? What are the symptoms are associated with this disease? What complications can occur with this disease? What meds are they on? What are the effects of this med? How is this disease affecting your patient? What should I as the nurse be looking for? Can they feed themselves? Can they dress themselves? What so their lungs sound like? IS there edema? How is this effecting their daily lives? What can I do to help them RIGHT NOW? What does the patient need RIGHT NOW! What can I do to help them, right now, to get better....feel better...and go home.

Students are far TOO focused on "THE LIST" and they forget that there is a patient that needs something. Then you can decide what label/definition/diagnosis applies to what they actually need.

A long time contributor, Daytonite (RIP) to AN made a critical thinking assessment sheet for students to help guide students to that Ah Ha moment. I had one for my students as well. I use Daytonites to keep her helping the students she so loved.

Daytonite:

critical thinking flow sheet for nursing students

student clinical report sheet for one patient

Edited by Esme12

Episteme

Specializes in Education, research, neuro. Has 43 years experience. 2 Articles; 182 Posts

Esme... I agree. I just keep scratching my head... what are we doing as educators that is causing this "diagnose first... and if all else fails, assess the patient" stuff. Because I gotta tell you... it is almost universal.

Episteme

Specializes in Education, research, neuro. Has 43 years experience. 2 Articles; 182 Posts

It's taken me a long time to warm up to NANDA-I. (It did not exist when I graduated.) I am seeing (after all these years) how it has elevated the profession and facilitated research.

But there is still this conundrum. The newer students conflate nursing diagnosis with the nursing process.

akulahawkRN, ADN, RN, EMT-P

Specializes in Emergency Department. Has 7 years experience. 3,486 Posts

I basically go head to toe, covering the systems as I go. I do this only so that I remember to address each system. It's an assessment system that I've used for a very long time and once you know what's going on and have had a chance to converse with the patient throughout the assessment, taken a gander at the labs, medical diagnoses, diet, etc... you really get a good look at what the patient needs and can then figure out the nursing diagnoses from there.

Get enough info and you won't have to think about picking the NDx, they'll practically yell themselves out to you!

calivianya, BSN, RN

Specializes in ICU. 2,418 Posts

Maybe I'm an oddball, but the only time I think about the term "nursing diagnosis" is when I'm on this forum. And I'm a recent grad, so I definitely had a lot of exposure to this Nanda business recently. I found it very unhelpful and that it hindered my learning.

I found the Nanda diagnoses very tedious and difficult as a student, and had trouble picking a nursing diagnosis out of a list, but... if you just let me in the room with the patient, I could tell you what they needed. I don't use the nursing diagnosis framework in my mind, though I suppose I do all of the steps.

For me it's more of, "Oh, my patient is in pain? I'll give the ordered Morphine, ask if it worked 30 minutes later, and if it did, I'm done with that problem. If not, and the patient is still A&O and not oversedated, I'll call the physician and see if we can give anything else." I think the Nanda list is a handicap. How about we just teach students to assess what the patients need, determine if it is within the nursing scope to fix or the medical scope to fix, fix it if we can, call the MD if we can't, and move on? Nursing diagnoses seem like a common sense thing, and if you really don't have the common sense to figure out what the patient needs, I just don't think a list of random phrases is going to help.

Maybe I'm just one of those crazy inexperienced nurses who doesn't know what she doesn't know, but I feel like limiting what I was able to do to a list made me more hesitant and took away my ability to think for myself at first. I couldn't think creatively, I had to check the list first to see if it was a problem on the official list of problems appropriate to nursing. IMO care plans don't help a budding nurse think critically - they help him/her follow a checklist, and I guess that's appropriate for stable, predictable patients. However, if the patient starts going down the tubes, I hope nobody checks the Nanda list before addressing the patient's problems!

Episteme

Specializes in Education, research, neuro. Has 43 years experience. 2 Articles; 182 Posts

You are a young nurse and still developing. The more you see, the more you potentially learn, the richer you'll be in your clinical reasoning. But let me push you a bit on a couple-three things:

1. You responded to the Nursing diagnosis issue but not so much the Assessment part of the discourse above. I am assuming that you do have a system of nursing assessment that is thorough and comprehensive and on-going throughout all your interactions with the patient. So... with that stipulated, let's just talk about nursing diagnosis and the nursing process.

2. What you DESCRIBED above is what I call the "see-a-hole-and-plug-it" nursing method. It's just really superficial... and some nurses even doll it up and apply NANDA's to it... but it isn't really the nursing process at all. Here's how it goes:

Assessment: Patient says pain is 8/10. Problem: Acute pain RT incision AEB "my pain is 8/10". Goal: Get pain to 3/10. Action:Give medication. Evaluation: W/in 45 minutes pain is 3/10.

Do you see how brain dead that type of reasoning is? How shallow? For this you went to nursing school, gave up 2-4 years of your life and went into debt??? (if you're like a lot of people today.) I tell my students that SAHAPI (see-a-hole-and-plug-it) nursing is sub-professional. It doesn't analyze where the patient is... and where they need to be... and what you're going to do to get them there. It's just running around putting out brush fires and doing customer service.

Again... I stipulated above that I suspect you DO in fact have a systematic means of assessing your patient. So, in spite of what you described, I would suspect also (or at least hope) that you do more thinking than your example would indicate.

3. The other reason the SAHAPI method you describe is sub-professional is that it is highly intuitive and thought-averse. You go into a room... patient looks uncomfortable and restless, you ask them if they hurt, they say yes, you give them morphine and 20 minutes later... your patient is tanking... you call a code... they're transferred to ICU... Cr*p!!! What just happened here? The patient was septic. The restlessness could have been the early change that heralded a bad turn of events. But you went with your intuition rather than exploring deeply what was actually happening and giving it a bit of thought.

You're not the odd-ball if you don't like NANDA. A lot of folks don't and don't use it minute-to-minute clinically. (There are reasons that we as a profession need to have NANDA-I and it's a robust topic for later discussion.) But you do need to be able to do full, rich, abundant, systematic assessment and formulate a list of basic human needs your patient is unable to meet on their own, you need to put them in a priority, you must set goals for the time you spend with your patient (how will the patient be better off after the 12 hours during which you cared for him?) develop a set of actions you'll employ to get the patient where he needs to be, and evaluate through the day what sort of progress the patient is making.

Edited by Episteme

amygarside

1,026 Posts

This is a very informative post. Thanks for sharing.

Joe V

Specializes in Programming / Strategist for allnurses. Has 26 years experience. 10 Articles; 2,063 Posts

merged duplicate topics

mimi90

14 Posts

This was very interesting to read. It's difficult to have to use Nanda verbage. I wish there was another way to verbalize patient needs after an assessment than going through a list

Do-over, ASN, RN

Specializes in CICU. 1,085 Posts

I learned from writing care plans in that I learned a systematic approach to addressing patient issues and that there should be a reason for everything we do TO or FOR a patient, and that we have to measure the outcomes. It is basically six sigma/DMAIC. The goal is to have a hundred "diagnoses" amalgamating in your head and recognizing how one affects the other, etc etc etc.

As far as the assessments go, well, I think one simply does not learn that in school. Sure, you learn where to place your stethoscope, how to palpate a pulse, etc. but you only learn how to synthesize it all to something useful with experience. A comprehensive assessment like the author described I think, can only be achieved after a couple years experience. Prior to that, the SAHAPI process is the only one a new nurse can use and stay sane and last long enough to become experienced.

FWIW, I have taught newbies that the most important assessment is the initial one you make from the doorway or foot of the bed. If the patient is really in trouble - you can often see it before you even touch them or lay a stethoscope on them. Aside from that, you have time to assess them thoroughly and review labs, etc.

Papa Nurse

4 Posts

When I was still working with students in a clinical situation, I had one piece of advice: "You can always do vital sign." The idea was unless it was obviously an emergent situation, if you weren't sure what to do, by taking VS, you could calm hyour mind down and begin to process the information before you.