Nursing assessment: the art and science of truly seeing a patient

Judy Foster MSN RN
A Worker's Speech To A Doctor Bertolt Brecht (1898-1956) When we come to you Our rags are tom off us And you listen all over our naked body. As to the cause of our illness One glance at our rags would Tell you more. It is the same cause that wears out Our bodies and our clothes.The pain in our shoulder comes You say, from the damp; and this is also the reason
For the stain on the wall of our flat.
So tell us:
Where does the damp come from?
Imagine that the worker in this poem is speaking to a nurse instead of a doctor. Would a nurse see the patient and his rags with the depth of understanding he is requesting? Nurses observe patients every day at their most vulnerable time. We observe people the sick, the dying, those giving birth, and a host of other states. We know what fear, frustration, helplessness, and suffering looks like because we observe it constantly.
 The challenge is to take our observations to a new level. Mere observations without actions are useless to the patient. Actions without insight may help the patient but does not convey our understanding. When we see the patient completely, we respond in a more meaningful way. To truly see a patient, requires focus, concentration, curiosity and an organized, systematic, approach . The purposes of this article are to explore the process of nursing assessment, provide a sample history and exam for nurses practicing in any setting and stimulate a new appreciation for this skill.
Lessons from Nightingale
Assessment has always been a part of nursing. In her famous work, Notes on Nursing , Florence Nightingale devoted a chapter entitled "Observation of the Sick". Ms. Nightingale began by asking nurses if a patient was "better"? The nurses replied to the question with " loose, vague opinions instead of facts". Ms. Nightingale didn't want to hear opinions. She wanted specific data to back-up a patient assessment. She wanted a professional model of observation. She defined the components of a professional assessment as follows:
"The most important practical lesson that can be given to nurses is to teach them what to observe-how to observe-what symptoms indicate improvement-what the reverse-which are of importance-which are of none-which are the evidence of neglect-what kind of neglect. All this is what ought to make part, and an essential part of the training of every nurse."
Assessment, a critical step in the nursing process

Table 1 Components of a nursing history: * Age, sex, * Patients description of the main problem or reason for visit. * Time course of illness: when it began, how long it has been a problem, current status, how the patient has managed the problem * Other signs and symptoms that accompany the problem/illness * Perception of the illness: what does the patient think caused the problem and how the problem affected the patient and family * Other medical or psychological problems * Social concerns: * living arrangements; type of housing, access to water, electricity * family structure, relationships, support network, * employment, finances, * highest level of education, * Religion and spiritual beliefs * Health habits, alcohol or drug intake, smoking history, * Prescribed medication * Home remedies or herbal remedies. * Allergies * Vaccinations * Review of body systems: neurological, cardiovascular, pulmonary, gastrointestinal, genitourinary, muscular-skeletal, skin, psychological other

More than 200 years later, we follow Ms. Nightingale's lessons on "what to observe". Commonly known as the Nursing Process, we observe and assist the sick utilizing a formalized, fact-based method. Nurses around the world use this same process to deliver holistic, patient focused, professional care. As the first step in the Nursing process, an accurate assessment provides a scientific basis for making the nursing diagnoses, planning the nursing care, implementing the nursing actions and finally, evaluating the patient's response to the care. During the assessment phase, the nurse gathers information about a patient's physiological, psychological, sociological and spiritual status. A thorough assessment is critical to identify the needs, preferences, abilities and problems of a patient. Once the data collection ends, the nurse organizes and analyzes the information. Essentially, the nurse is identifying: "What is happening right now?" and/or "What could happen in the future?" Following an assessment, the nurse determines the patient's actual problem(s) and the potential problem(s). The process continues with planning, implementation and evaluation.
Can we use a similar graphic with a Bengali nurse?
The Nursing Assessment: Part I, Health History
Nursing assessment can be broken down into two parts: Health History and Nursing Exam. The Health History is an exploration of the individual patient and his or her health status. It can be comprehensive or more specifically focused. The comprehensive history provides a holistic picture of the patient. The focused history targets one problem such as pain or difficulty breathing. In either case, the nurse obtains information about the patient's status, needs and problems. Some patients like to give lots of details and seem to wander off the subject. Other patients give short answers with little information. The nurse's time is valuable. A structured set of questions will help the patient focus and provide accurate details. Providing privacy and comfort is essential. A patient may not disclose certain information if family members or even strangers are nearby. Additionally, if the patient is in significant pain, he or she may not wish to communicate in detail or at all.
The data obtained from a health history can be either subjective or objective. Subjective data can't be measured or verified. A patient's perception or feeling related to their illness are examples of subjective data. When documenting subjective data, the nurse uses the exact words jr of the patient for example:" My left shoulder hurts".
Objective data can be directly observed, measured and/or verified. This data is based on specific facts such as "43 year old male with a past history of asthma, malnutrition". Table 1 presents some common components of a health history. Most nursing institutions use a standard nursing history form. Histories can be easily adopted to specific populations. Nurses working with pregnant women, children, cancer patients, or the elderly may want to add other relevant questions to their histories.
Important principles to remember in taking a Health History:
Provide privacy and comfort. If necessary, treat pain first.
Structure the history to obtain essential information.
Focus on patients status, needs and problems.
Adapt the history to specific populations of patients by adding or limiting questions.
The Nursing Assessment:
Part 2, Nursing Exam
Following the history, the Nursing examination of the patient commences. The exam consists of a systematic, head to toe assessment. As suggested in the interview process, provide an explanation of what you are about to do, ask the patient's permission and ensure privacy.
The exam contains four aspects or techniques: Inspection or examining the patient with your eyes, Auscultation or listening to the patient with a stethoscope, Percussion or tapping an aspect of the body and Palpation or touching a particular part of the body. Data from the health history helps to guide the examination. For example, the patient who complains of shoulder pain will have an examination that includes a thorough evaluation of that shoulder. A person without any pain in the shoulder, will have a brief exam of the shoulder but a focused exam involving their main complaint. Nursing exams improve with constant repetition. Table 2 presents an example of a comprehensive nursing physical examination.
Important principles to remember in performing a Nursing Exam:
Ask permission and explain the process.
Provide privacy.
Perform a systematic, head to toe assessment.
Utilize Inspection, Auscultation, Percussion, Palpation Requires practice, skill and constant refinement
NO TIME TO DO AN ASSESSMENT: "GRASP JUST ONE PEARL"
A nursing assessment requires practice, skill and constant refinement. Experienced nurses see a patient differently. Newer nurses may observe a patient but not recognize a problem. Lacking awareness of their own values, beliefs, or personal knowledge deficits, newer nurses are unable to separate important data from unimportant data.
For example, a patient may have all the signs, symptoms and complaints of a person experiencing a serious respiratory illness. Because the nurse has never "seen" this illness, she may act differently from an experienced nurse. A more senior nurse would immediately notice the patient's blue colored nail beds, rapid breathing, and the color of the sputum. She would recognize the seriousness of the illness and act more urgently. She clearly saw the patient and in seconds, responded to the situation.  It takes time to refine assessment skills. To stop, look, listen and understand what is going on requires.

Table 2 Components of a comprehensive nursing exam: A. General appearance and behavior assessment. Items to inspect: (1) Body build-thin, well nourished, overweight. (2) Pain behaviors: note grimacing, moaning, lying still or unable to remain still. (3) Gait - coordination and pattern of gait. (4) Hygiene, grooming - note cleanliness, body odors, appropriate dress for age and environment. (5) Signs of illness - note posture, skin color, respirations, nonverbal communications of pain or distress. (6) Affect, attitude, mood - note speech, facial expressions, ability to relax,  eye contact, behavior. (7) Cognitive process - note speech content and patterns, appropriate verbal responses. (8) Cognitive function - note the patient's intellectual process including perception, thinking, reasoning, and remembering. B. Vital Signs (1) Temperature (2) Blood Pressure (3) Pulse (4) Respiration (5) Measure pulse oxygen saturation if available (3) Pain assessment C. Head-to-toe assessment (1) Integumentary System Skin color assessment: cyanosis (dusky blue color in nail beds, lips, hands), jaundice (yellowish color in eyes, skin), pallor (paleness in conjunctivae, lips, face), erythema (redness of face) bleeding or bruising. (2) HEENT - Head, eyes, ears, nose, throat (inspection and palpation) Head - size, shape, symmetry, tenderness Eyes: Symmetry, alignment and movement of eyes, eyelashes, eyebrows, eyelids, pupils Ears: Palpate external ear for swelling, lesion or pain Throat - inspect lips, gums, teeth, tongue, hard and soft palates (3) Nervous System / Neurological Assessment Mental Status: Orientation level - person, place, time (4) Thorax and lungs (respiratory) (a) Inspection; shape of chest, breathing pattern, rate of respirations, (b) Palpation - detect areas of sensitivity, chest expansion during respiration (c) Auscultation - auscultate anterior and posterior fields (upper, middle, and lower lobes) for crackles, wheezes, absence of breath sounds. (5) Cardiovascular System (a) Inspect the neck and epigastric areas for visible pulsations (b) Palpate pulses and any areas of edema (c) Auscultate - Heart sounds (6) Gastrointestinal (a) Inspect the general shape of the abdomen, Note local bulges/scars, note color of scars (b) Auscultate each of four quadrants in a clockwise systematic manner (c) Palpate all four quadrants and note: muscle tightness, tenderness, masses (7) Genitourinary Inspection: Urine, if available for color, clarity, odor. (8) Musculoskeletal (a) Inspection and palpation: gait, muscles, joints especially if patient complains of pain.

Time is a precious part of a nurse's day. There is so much work to do. How is it possible to do this kind of assessment on every patient? The reality is that we can't. We can start slowly and gradually. Even focusing well on one aspect of an assessment will do wonders. There is an old saying, if you grasp just one pearl from a string necklace, you can't help but grasp the whole necklace. Over time, bit by bit, we grasp one pearl, then another then another. Before we know it, we become aware
of every bead. We see the whole person. Seeing patients in a comprehensive manner requires a kind of knowledge and wisdom that only occurs with time and practice.
Every patient interaction provides an opportunity to practice assessment skills. We must recognize the importance of concentrated observation. We need a curious mind that focuses intently on the patient.
When we assess patients at this level, we become the nurse that Nightingale wanted. Our next challenge is to become the nurse that the worker in the beginning of this article wanted.
Source: Nursing Magazine

 

Nursing assessment: the art and science of truly seeing a patient

Judy Foster MSN RN A Workers Speech To A Doctor Bertolt Brecht (1898-1956) When we come to you Our rags are tom off us And you listen all over our naked body. As to the cause of our illness One glance at our rags would Tell you more. It is the same cause that wears out Our bodies and our clothes.The pain in our shoulder comes You say, from the damp; and this is also the reason For the stain on the wall of our flat. So tell us: Where does the damp come from? Imagine that the worker in this poem is speaking to a nurse instead of a doctor. Would a nurse see the patient and his rags with the depth of understanding he is requesting? Nurses observe patients every day at their most vulnerable time. We observe people the sick, the dying, those giving birth, and a host of other states. We know what fear, frustration, helplessness, and suffering looks like because we observe it constantly. The challenge is to take our observations to a new level. Mere observations without actions are useless to the patient. Actions without insight may help the patient but does not convey our understanding. When we see the patient completely, we respond in a more meaningful way. To truly see a patient, requires focus, concentration, curiosity and an organized, systematic, approach . The purposes of this article are to explore the process of nursing assessment, provide a sample history and exam for nurses practicing in any setting and stimulate a new appreciation for this skill. Lessons from Nightingale Assessment has always been a part of nursing. In her famous work, Notes on Nursing , Florence Nightingale devoted a chapter entitled Observation of the Sick. Ms. Nightingale began by asking nurses if a patient was better? The nurses replied to the question with loose, vague opinions instead of facts. Ms. Nightingale didnt want to hear opinions. She wanted specific data to back-up a patient assessment. She wanted a professional model of observation. She defined the components of a professional assessment as follows: The most important practical lesson that can be given to nurses is to teach them what to observe-how to observe-what symptoms indicate improvement-what the reverse-which are of importance-which are of none-which are the evidence of neglect-what kind of neglect. All this is what ought to make part, and an essential part of the training of every nurse. Assessment, a critical step in the nursing process Table 1 Components of a nursing history: * Age, sex, * Patients description of the main problem or reason for visit. * Time course of illness: when it began, how long it has been a problem, current status, how the patient has managed the problem * Other signs and symptoms that accompany the problem/illness * Perception of the illness: what does the patient think caused the problem and how the problem affected the patient and family * Other medical or psychological problems * Social concerns: * living arrangements; type of housing, access to water, electricity * family structure, relationships, support network, * employment, finances, * highest level of education, * Religion and spiritual beliefs * Health habits, alcohol or drug intake, smoking history, * Prescribed medication * Home remedies or herbal remedies. * Allergies * Vaccinations * Review of body systems: neurological, cardiovascular, pulmonary, gastrointestinal, genitourinary, muscular-skeletal, skin, psychological other More than 200 years later, we follow Ms. Nightingales lessons on what to observe. Commonly known as the Nursing Process, we observe and assist the sick utilizing a formalized, fact-based method. Nurses around the world use this same process to deliver holistic, patient focused, professional care. As the first step in the Nursing process, an accurate assessment provides a scientific basis for making the nursing diagnoses, planning the nursing care, implementing the nursing actions and finally, evaluating the patients response to the care. During the assessment phase, the nurse gathers information about a patients physiological, psychological, sociological and spiritual status. A thorough assessment is critical to identify the needs, preferences, abilities and problems of a patient. Once the data collection ends, the nurse organizes and analyzes the information. Essentially, the nurse is identifying: What is happening right now? and/or What could happen in the future? Following an assessment, the nurse determines the patients actual problem(s) and the potential problem(s). The process continues with planning, implementation and evaluation. Can we use a similar graphic with a Bengali nurse? The Nursing Assessment: Part I, Health History Nursing assessment can be broken down into two parts: Health History and Nursing Exam. The Health History is an exploration of the individual patient and his or her health status. It can be comprehensive or more specifically focused. The comprehensive history provides a holistic picture of the patient. The focused history targets one problem such as pain or difficulty breathing. In either case, the nurse obtains information about the patients status, needs and problems. Some patients like to give lots of details and seem to wander off the subject. Other patients give short answers with little information. The nurses time is valuable. A structured set of questions will help the patient focus and provide accurate details. Providing privacy and comfort is essential. A patient may not disclose certain information if family members or even strangers are nearby. Additionally, if the patient is in significant pain, he or she may not wish to communicate in detail or at all. The data obtained from a health history can be either subjective or objective. Subjective data cant be measured or verified. A patients perception or feeling related to their illness are examples of subjective data. When documenting subjective data, the nurse uses the exact words jr of the patient for example: My left shoulder hurts. Objective data can be directly observed, measured and/or verified. This data is based on specific facts such as 43 year old male with a past history of asthma, malnutrition. Table 1 presents some common components of a health history. Most nursing institutions use a standard nursing history form. Histories can be easily adopted to specific populations. Nurses working with pregnant women, children, cancer patients, or the elderly may want to add other relevant questions to their histories. Important principles to remember in taking a Health History: Provide privacy and comfort. If necessary, treat pain first. Structure the history to obtain essential information. Focus on patients status, needs and problems. Adapt the history to specific populations of patients by adding or limiting questions. The Nursing Assessment: Part 2, Nursing Exam Following the history, the Nursing examination of the patient commences. The exam consists of a systematic, head to toe assessment. As suggested in the interview process, provide an explanation of what you are about to do, ask the patients permission and ensure privacy. The exam contains four aspects or techniques: Inspection or examining the patient with your eyes, Auscultation or listening to the patient with a stethoscope, Percussion or tapping an aspect of the body and Palpation or touching a particular part of the body. Data from the health history helps to guide the examination. For example, the patient who complains of shoulder pain will have an examination that includes a thorough evaluation of that shoulder. A person without any pain in the shoulder, will have a brief exam of the shoulder but a focused exam involving their main complaint. Nursing exams improve with constant repetition. Table 2 presents an example of a comprehensive nursing physical examination. Important principles to remember in performing a Nursing Exam: Ask permission and explain the process. Provide privacy. Perform a systematic, head to toe assessment. Utilize Inspection, Auscultation, Percussion, Palpation Requires practice, skill and constant refinement NO TIME TO DO AN ASSESSMENT: GRASP JUST ONE PEARL A nursing assessment requires practice, skill and constant refinement. Experienced nurses see a patient differently. Newer nurses may observe a patient but not recognize a problem. Lacking awareness of their own values, beliefs, or personal knowledge deficits, newer nurses are unable to separate important data from unimportant data. For example, a patient may have all the signs, symptoms and complaints of a person experiencing a serious respiratory illness. Because the nurse has never seen this illness, she may act differently from an experienced nurse. A more senior nurse would immediately notice the patients blue colored nail beds, rapid breathing, and the color of the sputum. She would recognize the seriousness of the illness and act more urgently. She clearly saw the patient and in seconds, responded to the situation. It takes time to refine assessment skills. To stop, look, listen and understand what is going on requires. Table 2 Components of a comprehensive nursing exam: A. General appearance and behavior assessment. Items to inspect: (1) Body build-thin, well nourished, overweight. (2) Pain behaviors: note grimacing, moaning, lying still or unable to remain still. (3) Gait - coordination and pattern of gait. (4) Hygiene, grooming - note cleanliness, body odors, appropriate dress for age and environment. (5) Signs of illness - note posture, skin color, respirations, nonverbal communications of pain or distress. (6) Affect, attitude, mood - note speech, facial expressions, ability to relax, eye contact, behavior. (7) Cognitive process - note speech content and patterns, appropriate verbal responses. (8) Cognitive function - note the patients intellectual process including perception, thinking, reasoning, and remembering. B. Vital Signs (1) Temperature (2) Blood Pressure (3) Pulse (4) Respiration (5) Measure pulse oxygen saturation if available (3) Pain assessment C. Head-to-toe assessment (1) Integumentary System Skin color assessment: cyanosis (dusky blue color in nail beds, lips, hands), jaundice (yellowish color in eyes, skin), pallor (paleness in conjunctivae, lips, face), erythema (redness of face) bleeding or bruising. (2) HEENT - Head, eyes, ears, nose, throat (inspection and palpation) Head - size, shape, symmetry, tenderness Eyes: Symmetry, alignment and movement of eyes, eyelashes, eyebrows, eyelids, pupils Ears: Palpate external ear for swelling, lesion or pain Throat - inspect lips, gums, teeth, tongue, hard and soft palates (3) Nervous System / Neurological Assessment Mental Status: Orientation level - person, place, time (4) Thorax and lungs (respiratory) (a) Inspection; shape of chest, breathing pattern, rate of respirations, (b) Palpation - detect areas of sensitivity, chest expansion during respiration (c) Auscultation - auscultate anterior and posterior fields (upper, middle, and lower lobes) for crackles, wheezes, absence of breath sounds. (5) Cardiovascular System (a) Inspect the neck and epigastric areas for visible pulsations (b) Palpate pulses and any areas of edema (c) Auscultate - Heart sounds (6) Gastrointestinal (a) Inspect the general shape of the abdomen, Note local bulges/scars, note color of scars (b) Auscultate each of four quadrants in a clockwise systematic manner (c) Palpate all four quadrants and note: muscle tightness, tenderness, masses (7) Genitourinary Inspection: Urine, if available for color, clarity, odor. (8) Musculoskeletal (a) Inspection and palpation: gait, muscles, joints especially if patient complains of pain. Time is a precious part of a nurses day. There is so much work to do. How is it possible to do this kind of assessment on every patient? The reality is that we cant. We can start slowly and gradually. Even focusing well on one aspect of an assessment will do wonders. There is an old saying, if you grasp just one pearl from a string necklace, you cant help but grasp the whole necklace. Over time, bit by bit, we grasp one pearl, then another then another. Before we know it, we become aware of every bead. We see the whole person. Seeing patients in a comprehensive manner requires a kind of knowledge and wisdom that only occurs with time and practice. Every patient interaction provides an opportunity to practice assessment skills. We must recognize the importance of concentrated observation. We need a curious mind that focuses intently on the patient. When we assess patients at this level, we become the nurse that Nightingale wanted. Our next challenge is to become the nurse that the worker in the beginning of this article wanted. Source: Nursing Magazine