Decoding Patient Health Through Comprehensive Assessment

[Julita, BSN, RN]

Decoding Patient Health Through Comprehensive Assessment

In the healthcare environment, a patient's story unfolds through a nuanced interplay of symptoms, history and aspirations. Patient assessment, an intricate art of merging science and empathy, offers a glimpse into the detailed tapestry of one's health. It's more than just diagnosing; it's deciphering the silent language of the body and soul. This article ventures into the delicate arena of patient assessment, revealing how understanding the human narrative is paramount in providing compassionate and patient-centered healthcare.

This discussion will address the general principles of patient assessment. Other types of assessments will not be discussed here because they require an in-depth analysis.

What is patient assessment?

Patient assessment is the structured acquisition of information from the patient^1,6 or other sources in order to identify the patient's needs and design an individualized care plan. It is the first stage of the Nursing Process^3,6 it precedes everything else. This initial step in care planning is very crucial in the patient's journey whether in hospital, a private clinic or community setting.

Assessment involves putting together the information gathered, documenting it clearly and analyzing the data in order to make sense of that information. Many aspects of care can be assessed but generally it depends on the clinical setting and the nature of the patient's visit. Assessment is a priority and not an option. When done well; assessment provides clear guidelines to healthcare professionals and sets the patient journey in the right direction.

Who is eligible for assessment?

Assessment can be done on;

·         New patients on admission to the clinic, hospital or service

·         Existing in-patients through on-going re-assessments of their treatments

·         Emergency patients where multiple assessments are done due to the urgency              of their presenting clinical condition

·         Unconscious patients especially in ICU, Operating Theaters and Recovery                      rooms

·         Patients waiting to be discharged to check if they are fit to go home or be                      transferred to another care facility

Usually, verbal consent is obtained right at the beginning except for those patients who may be unconscious.

What do we assess?

Assessment can include the following criteria⁶ but is not limited to these alone.

·         Physical appearance / disabilities

·         Emotional status

·         Psychological / mental status

·         Vital signs

·         Socio-cultural needs

·         Spiritual needs

·         Economic needs

·         Life-style behaviors

·         Nutritional needs

Assessment is a key nursing skill that should be performed for all patients receiving care regardless of their clinical environment.

What questions do we ask during an assessment?

There are specific and general questions to ask patients so you can gather more information. The rule of thumb in gathering information from patients is to ask them enough open-ended questions so they can explain fully what their immediate needs are. As healthcare professionals, we need to pay attention to the responses that patients share during their assessment.

Good communication skills⁶ and interpersonal skills are paramount during this process. When patients answer questions, we get more insight into what's happening and can formulate more questions based on their responses. Sometimes during assessment, we ask patients many questions repeatedly to yield more results.

Generally, we ask them their;

·         name

·         age

·         home address

·         occupation

·         allergies

·         medications

·         medical history

·         family history

·         hereditary conditions

·         any implantable devices

·         any pregnancy ( if applicable )

·         presenting symptoms

·         when the symptoms started

·         what has helped in the past?

·         what triggers the symptoms?

Those are some of the questions that may be relevant for assessment. At the end of your assessment, all the findings gathered must be clearly and coherently documented as per organization guidelines.

Why do we assess patients?

There are varied reasons why we perform assessments.

·         to gather information about the patient

·         to get to know the patient

·         to identify clinical needs

·         to identify goals for care planning

·         to determine if we are the right people to help this patient

·         so we can offer our services to the patient

·         so we can start treatment

·         so we can make referrals appropriately

We assess patients, looking to gain information that we may not have beforehand. We want to know why the patient has come to see a healthcare professional. The information collected is important to aid with the diagnosis of the patient's condition.

When is patient assessment done?

Patient assessment is done at the beginning of the patient's visit to a care facility, right from the moment you meet the patient. It is implemented immediately;

·         on admission

·         before commencing treatment

·         post-treatment

·         during the patient's stay in the hospital

·         at the beginning of every shift

·         when clinical needs change

We routinely monitor patients' condition re-assessing³ the parameters that we assessed before and any new developments. After we implement the solutions to the problems identified, we assess the effectiveness of the treatment until favorable outcomes are achieved. Re-assessments are done frequently or less frequently depending on the clinical condition of the patient. Assessment is ongoing until the patient is discharged⁴.

Where is assessment done?

As nurses, we are always told to maintain confidentiality while doing patient assessments. Maintaining patient confidentiality is both "an ethical and legal responsibility for health professionals"⁵. In the past there were rooms dedicated specifically for assessing new patients. Patient assessment can be done;

·         in hospitals

·         in clinics

·         at home

·         in the doctor's office

·         in the hallways

·         in procedure rooms

·         by the patient's bedside area

·         over the phone

·         via video calls

Different healthcare settings apply different rules in regards to the place of assessment. Many clinical areas do not have any dedicated areas or rooms for assessment. It is good practice to follow your organizational guidelines. Normally we draw the curtains around the patient's bedside area and begin asking them important questions about their life. It is very challenging when doing assessments at the bedside area because some patients do not hear very well.

Sometimes, our voices will be raised in order to be heard making it very difficult to maintain confidentiality or privacy in that environment. Nevertheless, most healthcare staff will strive to maintain patient confidentiality given the circumstances of healthcare practice today.

How is patient assessment done?

Assessment must be done systematically and comprehensively⁴. All the crucial questions should be thoroughly captured during this stage. Primarily assessments were done face-to-face but now healthcare policies and guidelines have been modified in regards to patient assessment.

Now we have virtual assessments, done through social media platforms. These can be very challenging due to a lack of physical interaction with the patients. Virtual assessments have become the norm, especially after the recent pandemic². Many patients needed to see their physicians but because of lock-downs, the most convenient way was to have virtual appointments.

However, it is important to note that patient assessment should not be;

·         rushed

·         interrupted

·         hurried

·         biased

·         forced or coerced

·         minimized

·         substituted / replaced by electronic equipment

In the past, there was pre-assessments where patients would come and be assessed days or weeks prior to their procedure date. That too has since changed, and very few care facilities are still performing pre-assessment services. The change from pre-assessment could be a result of many challenges faced by healthcare facilities today.

Today many patients come to the hospital and have their assessment done on the same day of the procedure. Usually they arrive 1 – 2hrs before their scheduled procedure time.

The subjective / objective assessment process

Assessment is done in partnership with the patient¹, sometimes with the help of their loved ones, a carer or someone who really knows the patient's medical history. Assessment is not only verbal it can also be non-verbal.

Subjective assessment;

·         it utilizes verbal responses

·         the patient describes how they feel

·         the answers given are unique to the patient

·         there is no right or wrong answer

Objective assessment;

• ·         it is non-verbal
•           utilizes electronic equipment
• ·         gives an objective judgment / result

Through objective assessment we can obtain additional information;

·         from the patient's chart

·         investigational results, X-Rays, CT, MRI, blood tests

·         previous admission reports

·         by measuring the patient's vital signs e.g BP, pulse, respirations, temperature,             oxygen saturation, blood glucose levels etc

All these sources of information give us the background history of the patient, without talking to the patient; this is vital when dealing with unconscious patients.

Tools used to assess patients

Various tools are used in assessing patients depending on their clinical situation. Below are some of the common tools⁶ used.

·         Glasgow coma scale

·         Waterlow scale

·         AVPU

·         MEWS

·         CAGE / CIWA-AR

·         Pain charts

·         Stool charts

·         Fluid intake / output charts

·         Food charts

·         Neurological charts

·         Wound charts

These tools are important for recording accurate information in order to deliver quality care.

Barriers to assessment can be;

·         lack of understanding

·         short-term memory

·         lack of private rooms

·         language barriers

·         hearing problems

·         confused patients

·         environmental issues I.e. noise, heat, cold

·         cultural barriers

·         anxiety

·         healthcare professionals using jargon

·         patient not interested/compliant

·         lack of protected time

·         emergency situations

The use of jargon by healthcare providers can be avoided by explaining things in simple terms. Simple phrases can help patients to comprehend what is being assessed and what is required of them. Through experience, we learn the art of rephrasing the questions in order to gain meaningful answers that we need from the patient.

Conclusion

We can all agree that a thorough, detailed and comprehensive assessment is critical in guiding healthcare professionals to choose the appropriate treatment therapies. Patient assessment is the responsibility of all care providers, collaborating to provide an unforgettable patient experience. Assessment is not just done once, rather it is a continual practice. Even though some aspects of patient care have changed throughout the decades, the essence of assessment still remains primarily for information gathering in order to plan care.

References

¹Assessing the patient's needs and planning effective care.

²Virtual care and COVID-19: A survey study of adoption, satisfaction and continuing education preferences of healthcare providers in Newfoundland and Labrador, Canada.

³Application of the nursing process in a complex healthcare environment.

⁴Clinical practice guidelines for comprehensive patient assessment in emergency care: A quality evaluation study.

⁵Health professionals' knowledge and attitude towards patient confidentiality and associated factors in a resource-limited setting: a cross-sectional study.

⁶Nursing Admission Assessment and Examination.

 

[Ciann]

Very good article.  Nursing assessment is what I do in a staging position for an outpatient clinic.  I have recently been challenged with using a new computer system to enter nursing assessments (previously done for past 20 years on paper). Being new to computers and a new system, I am slow to learn , but feel I improve daily.  I have been told by my supervisor, I am taking too long with patients, entering too many comments in my assessment, and the doctors are not happy with the turn around time in getting the patient ready for procedure. My anxiety is through the roof.  I have been told in no uncertain terms how they want me to do my assessment so it helps them put through more patients. I don't know how I can leave out and ignore information the patient reports to me during assessment which is the only way I could accommodate them.  The new system has caused many problems with nurses charting under other nurses logins in error, with supervisor not aware of how corrections are to be made. I'm very legal minded, and know all too well the importance of accurate documentation.   I'm not seeing that  importance emphasized  with this new roll out of technology. Risk management is nearly invisible and unreachable, and I am not sure they had much input in this new system.  I am concerned for my job as I am not willing to compromise my nursing assessment , patient care,  and documentation to accommodate the speed in which the doctors want to put through each patient. 
Thank you for this article as it gives me strength and hope to carry on with accurate, informative nursing assessments. 
C
 

[Julita, BSN, RN]

Thank you Ciann I am glad you enjoyed reading it. And I totally agree with you as you highlighted the challenges of computerized assessments. I felt the same way too when they introduced computerized care plans at my hospital many years ago.It can be a challenge.We just have to do the best we can.Happy nursing ☺️