When All Else Fails... Assess Your Patient!

[Episteme]

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.

[exp626]

I'm really enjoying this article and dialogue. This may over-simplify a comprehensive assessment, but I've thought of the assessment as peeling back the layers of an onion (no disrespect to my patients intended). This analogy has been particularly helpful as a reminder to continue my assessment if something doesn't seem right with my patient, and I want to get to the root of the problem.

[Esme12, ASN, BSN, RN]

I don't think it over simplifies it I think we make it over complicated.

[smf0903]

This is such an interesting thread. When I read the title "When all else fails, assess your patient", I thought "Whaaaat?!?! Isn't that the FIRST thing we should be doing??" (But I get the title after reading the article ) One thing I have observed in clinicals is the number of nurses and students who do not assess their patients when they get to the floor. I absolutely do not understand how you can care for someone without first having assessed them, I really don't. We go in the evening prior to our clinical days to pull up labs, radiology, H&Ps, etc on our patients, and almost every single patient looks different on paper than they do after an assessment. I think assessments are the single most important thing we do...otherwise how do we know what that patient's needs are? How do we gauge decline/improvement during our shift?

I really enjoyed the article...very informative!

[casi, ASN, RN]

One of the things that drove me crazy and I argued several times is the practice of needing to have a full care plan with nursing diagnosis put together BEFORE I even touched the patient with just the information I pulled from the chart. I could get a pretty good idea of what the patient needed by reading an H&P and nursing notes, but it wasn't enough to formulate a comprehensive plan of care. I needed to get in and see the patient first. What one nurse see's isn't always what the next is going to see.

Many people argue that NANDA isn't used in the real work. I work in LTC/TCU where everyone has to have a care plan. I'm not sure if they follow NANDA dxs or not, but it's a very similar process.

[elixRN, BSN, RN]

I am a fairly new nurse (1.5 years) I work on a very busy acute medical unit, with sometimes poor staffing. I always assess my patients first thing, read the h&p get lab values and plan out my day. I am pretty good at seeing the full picture, like realizing when someone is going septic or going into acute renal failure, but the last thing I am worried about is what my exact NANDA diagnosis is gonna be. How i usually do things: What does this patient need now, and what is the plan for the day? If that plan changes quickly, ( as they often do) I usually know what to do, if I don't I ask someone with more experience, or I call the doctor. And how can I provide that to all 6-8 patients? That's what I am worried about. Going by the book and writing down a thought out "care plan" is not on my priority list.

[elixRN, BSN, RN]

It's not to say I don't think the NANDA DX isn't important, I do think it is important. But its just difficult to think about, when you have a limited amount of time to do a lot of tasks for a lot of patients. How do I fit it in with all the other things going on?

PS we pretty much just have to write shift summaries for our patients, and the nursing care plans are just "pick a couple and click on the computer"

[Episteme]

elixRN: Good news! I honestly have never met a nurse who uses NANDA on the fly... predicating all they do for a patient in-the-moment on how they frame the diagnosis. So you're not alone.

But you said something I found very interesting. You described how you start with a pretty darn thorough data collection... and then you stated you "plan the day." You have multiple patients with multiple problems (not to mention the pressure you're under to do massive amounts of mandatory documentation)...

So... here's my question... on what basis do you plan your day? How do you decide what to do first, second and so on? "Care Planning" is a big hairy deal and we do tend to drop it (or highly modify it) when we graduate. It seems clear you're making use of the nursing process and I'm curious how you put your to-do list in order.

Thanks.

[elixRN, BSN, RN]

Epistme: thanks the response. How do i make my plan? Well thats a loaded question because things NEVER go as planned, but how my day goes is as follows:

usually during report I find out the most important info about each pt, then I write down what time meds are due for each pt, and if they have any procedures that day that I have to do, such as paritoneal dialysis or if they need a blood transfusion. Any extra tasks that can be done at any time such as getting a consent signed, I write on the side, so I can cross them off as I do them. Then I go along and assess each patient, usually in order of acuity or just in room order if they are all fairly stable. If there are any issues i can deal with immediately like a high blood sugar, or a sky high BP i do that first, before I even assess other patients. At this point i know what each pt needs for the day; and if they are lucky I write that on their white board. Then if all goes well I start my med pass at 8am. I try to get that done by 10am,. There are always interruptions; doctors, lab techs, PT, OT, patients needing pain meds and so on.So I am always re-prioritizing basically minute-to-minuite. After dealing with the distraction, I go back to what needs to be done within a time limit, just going down the list. Once I have my morning meds passed I can do other tasks, making sure I check for new orders constantly and charting every chance I get. And that's basically how it goes. Every day is different and every patient is different.

When I comes to care plans I guess I do actually do them, because I do have goals for each patient during the day, even if its just " give insulin to bring down high blood sugar"

[elixRN, BSN, RN]

And I also use the nursing process, its just happens to be rapid fire nursing process...

[calivianya, BSN, RN]

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:

(snipped for brevity)

You're right - I do a very in depth assessment and I do think about why what's going on is going on instead of just fixing one problem at a time. I do not believe that the NANDA list helped me develop that skill, though - I think it was experience, assessing my patients with a preceptor or my nursing instructor, asking if they were hearing what I was hearing, exploring why I was hearing that, etc. I don't think paper care plans helped either, just because ours were so NANDA-focused. I was creating a plan to treat a phrase and come up with fancy terms related to that phrase instead of coming up with a plan to treat a patient. Paper care plans and treatment of people are not at all similar in my mind, but I will give them the benefit of the doubt and say that maybe they are helpful to someone with a different learning style.

That is more of what I meant when I said I'd see what a patient needed. It's not just about what the patient can tell me verbally, it's also about what their body is telling me. My example was indeed very limited because I usually don't find one hole to plug - there are usually quite a few going on at once.

[Episteme]

I actually bought the NANDA book. I have NOC and NIC Linkages coming, not yet arrived. I spent a good amount of time in Chapter 3 Nursing Diagnosis in Education. I found it very interesting but also condemning. I think our school should have read this book before faculty (especially in fundies) set out to teach nursing process and nursing diagnosis.

Although obviously the book supports what we know of as "the list"... they also point out that

"Faculty should not assume that the concept and implementation of the nursing process concept is easy for students to grasp, as it is a very complex way of processing information especially for the beginning student. Faculty need to provide suficient time for students to practice developing their nursing process skills..." They go on to say that "students have difficulty determining what data support a particular diagnosis."

BUT... what they did in our school, was to make "THE BIG CAREPLAN" a project that had a LOT of points attached to it. (Mind you, this is in Fundies.) Then when the students struggled and couldn't come up with diagnoses, they implied that the students obviously couldn't THINK like nurses. (Well, duh!) So you had Fundies students passing their theory course in danger of getting unsatisfactory in the clinical and lab components.

I wish I'd read this book 3 years ago. There were some seriously nutted up students who matriculated to my Med-Surg class including one male student who would break down in tears whenever the topic of nursing diagnoses came up.

Long story short... it IS an acquired skill and takes time and experience to learn and use properly. We stopped treating our new students that way. I hope there are not other schools still putting that burden on their shoulders too quickly.

[Natasha A., CNA, LVN]

Thank you for writing this great post and very happy I found it on the forum. :)