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Patient assessment is an important component of any nurse's role. It allows patient care to be prioritised in an appropriate manner and it forms the basis of nursing care plans both of which impact on patient outcomes.
Assessment is an ongoing process that occurs a multitude of times during a patient's stay, with the frequency being determined by individual patient acuity. If patient assessment is not thorough, important information may be missed, which may impact on the patient's progress. Therefore it is essential to have a system of evaluating and assessing patients that is comprehensive and allows for prioritisation of patient needs.
Identifying which patient needs to be assessed first can be quickly achieved by `looks good versus looks bad'" while a more thorough assessment of patients can follow using a `primary and secondary assessment'2. These issues will be highlighted using the following case scenario.
At the start of a night duty shift you go to check on your six ward patients when you notice Mr Daniels. You have an intuitive feeling that he is unwell just from looking at him across the room. You know the resident doctor is busy and he has a number of patients waiting to be seen. You need to give the doctor a clear history to allow the patient to be prioritised correctly. You also may need to implement nursing interventions to care for Mr Daniels.
This is a scenario that frequently confronts Registered Nurses, therefore it is helpful to have some strategies to comprehensively assess patients and prioritise care. This article will discuss an assessment format used for trauma patients on admission to emergency departments, but can easily be adapted to the assessment of the ward patient. It will discuss the issues as they relate to Mr Daniels.
Nurses often describe having an intuitive feeling that a patient is unwell and needs assessment even if they sometimes have difficulty identifying exactly what is wrong. In paediatrics, many nurses use an assessment tool called 'looks good versus looks bad, when assessing children, but it is also a good assessment to use on adults. At a glance you observe the following information: colour, skin perfusion, level of activity, responsiveness and position of comfort.3
Across the room you notice that Mr...