Nursing assessment is one of the main stages of the nursing process. According to Webster’s dictionary, “nursing assessment is the gathering of information about a patient’s physical, psychological, sociological, and spiritual status”. As professional nurse’s, we are responsible to use skills to complete assessments on every patient that we care for. Collecting this information allows us to prioritize the care and initiate interventions. How well we assess our patients determines if there is a positive or negative outcome. One positive outcome, that occurred
from utilizing complete assessment skills, happened when I worked in a long term care facility. First of all, the frequency of a complete assessment varies in different health care settings. (Jensen, 2011). Working in a nursing home many of the residents only require once a month thorough head to toe assessments. However, there is a more acute area in the facility, and this was where my assessment skills and interventions led to a positive outcome. Poor Mary Jane (fictitious name), a 75 year old frail female, had multiple urinary tract infections (UTI), and was put on IV antibiotics.
This was the first day I cared for her, but the fourth day of being on the antibiotics. I recall assessing the IV site and listening to her lungs and while I was doing this I noticed her back was broken out in hives! I thought…she was having an adverse reaction to the medication. Studies show that older people in long-term care facilities suffer from a higher number of adverse drug reactions. One study conducted estimated that forty-two percent of adverse drug reactions were preventable. (Jordan, 2007) After assessing her upper body I then assessed her lower extremities and noticed smaller hives initiating on her lower extremities.
She wasn’t having any difficulty breathing, her lungs were clear, and I asked if she was itchy and for how long? To my astonishment she informed me that she had felt like that for 2 days and had even told the other nurses. I checked her temperature and it was 99. 5. Right away I notified the doctor who then discontinued the IV medication. She was then given Benadryl and measures to make her comfortable were administered. To this day I wondered, prior to my assessment, if her lungs were ever checked? How was that missed and what an awful outcome could have transpired if an
accurate assessment wasn’t completed and if the medication wasn’t terminated. I remember the next time I cared for her she thanked me and claimed I may have saved her life. That was a great feeling and I was proud to be a nurse. Looking back I realize patient education may have come into play and Mary Jane perhaps was informed of the signs and symptoms of an adverse drug reaction, and did let the nurse know. The problem occurred with the other health care professionals that cared for her who failed to listen and more importantly didn’t assess the physical condition of this patient.
I feel that a yearly in-service on proper physical assessment should commence, and that all health care members attend. In closing , I will state that nursing assessment is vital to achieving a positive outcome and necessary in order to improve a patients health status. As Rubenstein, Calkins, and Greenfield stated, “ few people would dispute the assertion that good quality and effective care for older people is influenced by the use of comprehensive, client specific assessment” (Rubenstein, 1998). References “Nursing assessment”. (n. d. ). Webster’s Online Dictionary with Multilingual Thesaurus Translation.
Retrieved August 25, 2012, from http://www. websters-online- dictionary. org/definitions/nursing+assessment#top Jensen, S. (2011). Nursing Health Assessment: A Best Practice Approach. Philadelphia, Pa: Wolters Kluwer Health/Lippencott, Williams ; Wilkens Publishing, ISBN -13 978-0-7817-8062-9 Jordan, S. (2007). Adverse drug reactions: reducing the burden of treatment. Nursing Standard, 21(34), 35-41 Rubenstein L. , Calkins D. , Greenfield D. ,et al. (1998) Systemic Biases In Functional Status Assessment Of Elderly Adults: effects of different data sources. Journal of Gerontology. 1998;37:562-569.