Nursing Assessment

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Nursing Assessment

Joann Campbell

Palm Beach State College

August 26, 2012

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-...
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