Write a Physical Assessment
Writing a physical assessment is the first step nurses take when collecting data on a patient. The assessment is done in writing because the results will need to be validated, organized, analyzed and then recorded on the patient's chart. Nurses strive to obtain a complete health record before doctors perform an examination resulting in a diagnosis and suggested treatment plan. The two main types of data used by nurses to write a physical assessment are subjective data, which is collected from interviewing the patient and family members, and objective data, which is based on direct observation.
Instructions
1. Find out which type of assessment you must perform. For example, write "initial assessments" as soon as possible after the patient is admitted to the hospital. If you're writing a "problem-focused assessment," you must know what questions will help you determine the status of the problem the patient reported in the initial assessment. "Emergency assessments" are written immediately, usually as the patient is being treated for a serious condition. A "time-lapsed assessment" is done at certain intervals, usually so the doctor can decide whether treatment has helped the patient.
2. Begin the physical assessment by noting the patient's current complaints. According to Nursingcrib.com, you can find out about the patient's symptoms by asking the patient, speaking to a family member, or asking another nurse or doctor who has cared for the patient.
3. Observe the patient and then record your findings under the section for "objective data." Doctors at Medlaw.com suggest, nurses take notice of whether the patient seems lethargic or full of energy, is able to walk without assistance, can climb on the examination table without help, has difficulty sitting or standing for several minutes, seems coherent.
4. Gather information to complete a nursing health history. Nursingcrib.com breaks this information down into the following ten categories: biographical data, reason the patient is seeking care, a history of the presenting condition, the patient's medical history (including operations and immunizations), a review of systems, specifics about the patient's lifestyle (sleep patterns, habits, diet), social information (relationships, work), psychological data and pattern of medical care (whether the patient has a primary physician).
5. "Spend more time listening" is how NurseReview.org suggests that nurses can obtain a wealth of information directly from the patient and the patient's family. NurseReview.org also recommends that nurses learn ask open- and closed-ended questions. Open-ended questions encourage the patient to talk freely and reveal information that the patient believes is irrelevant, but which could help a doctor in making a diagnosis.
Tags: about patient, assessment done, assessment must, data which, nurses take, objective data, patient family
