Fundamentals of Medical-Surgical Nursing

A Systems Approach

Anne-Marie Brady, Catherine McCabe, Margaret McCann

• Publisher: Wiley-Blackwell
• Year: 2013
• ISBN:
  9781118490938
• Edition: 1
• Topic: Medicine
• Subtopic: Nursing

Fundamentals of Medical-Surgical Nursing

Fundamentals of Medical-Surgical Nursing

A Systems Approach

Fundamentals of Medical-Surgical Nursing is a comprehensive yet easy-to-read overview of medical and surgical nursing, designed specifically to support all nursing students learning to care for the adult patient. Highly illustrated and with an easy-to-follow systems-based structure, it provides a thorough foundation in anatomy and physiology, pathophysiology, medical management, and nursing care for the full spectrum of adult health conditions.

KEY FEATURES:

• Extensive coverage of principles of nursing assessment, medication administration, infection prevention and control, and nutritional care
• Key need-to-know-information and definitions for the anatomy, physiology, and pathology of a range of illnesses and conditions
• Detailed overviews of nursing care, including patient education, treatment, and complications
• An online resource centre with a range of extras for both lecturers and students, including case studies, reflective activities, interactive multiple choice questions, and further reading lists

Fundamentals of Medical-Surgical Nursing is the ideal textbook to help students succeed on their adult nursing course.

with online self-test

www.wileyfundamentalseries.com/medicalnursing

• Interactive multiple-choice questions
• Reflective questions for downloading
• Case studies
• Links to online resources

When you purchase the book you also receive access to the Wiley E-Text: Powered by VitalSource. This is an interactive digital version of the book, featuring downloadable text and images, highlighting and notetaking facilities, bookmarking, cross-referencing, in-text searching, and linking to references and abbreviations. Fundamentals of Medical-Surgical Nursing is also available on CourseSmart, offering extra functionality as well as an immediate way to access the book. For more details, see www.coursesmart.co.uk/9780470658239.

Part 1

Common Principles Underlying Medical and Surgical Nursing Practice

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Chapter 1 Principles of nursing assessment

Chapter 2 Principles of drug administration

Chapter 3 Principles of intravenous therapy

Chapter 4 Principles of nutritional care

Chapter 5 Principles of infection prevention and control

Chapter 6 Principles of acute care for older people

Chapter 7 Principles of end of life care

Chapter 8 Principles of perioperative nursing

Chapter 9 Principles of high-dependency nursing

Chapter 10 Principles of emergency nursing

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1

Principles of nursing assessment

Naomi Elliott

School of Nursing and Midwifery, Trinity College Dublin, Dublin, Ireland

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Contents

Introduction

The purpose of nursing assessment

Assessment frameworks

Methods of assessment

Rapid assessment of the acutely ill patient

Documenting patient assessment and record-keeping

Conclusion

References

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Learning outcomes

This chapter will examine the WHY, WHAT, HOW questions of nursing assessment. It will enable you to ask:

• Why – to explain the purpose of nursing assessment and why it is vital to quality patient care
• What – to consider what patient information is collected and the rationale for using an assessment framework
• How – to identify a range of methods available to assess patients and collect information that support clinical decision-making and individualised patient care plans.

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Introduction

Assessment is the first step in determining the condition of the patient's health and their immediate and long-term needs. The nursing assessment of patients on admission to hospital or on attendance at clinics is key to clinical decision-making and to planning patient care that takes account of the individual patients' needs and circumstances. Nurses have responsibility for carrying out the initial and ongoing patient assessments, for initiating interventions that take patients' needs into consideration and for evaluating the effectiveness of these interventions.

The nursing assessment is one component within a larger, multidisciplinary team assessment during which the patient is assessed by different healthcare professionals as part of the care pathway and patient referral process. A multifactorial assessment of the older person for falls, for example, can involve the nurse, doctor, physiotherapist, occupational therapist, optician and other healthcare professionals working in specialist areas of practice such as cardiac assessment. As a member of the multidisciplinary team, the nurse often plays a key role in coordinating the patient assessment and ensuring that appropriate referrals are made and followed up.

The principles of nursing assessment presented in this chapter are in line with the national guidelines from the professional nursing board in Ireland, An Bord Altranais, and in the UK the Nursing and Midwifery Council (NMC). The principles need to be read in conjunction with local policies and procedures for the nursing assessment, which are usually set by the hospital or healthcare employer. At ward or unit level, more specific assessment procedures may apply; for example, cerebrovascular or stroke units may include an assessment of swallowing and mood as part of the assessment of a patient newly diagnosed with a cerebrovascular accident – a stroke.

The purpose of nursing assessment

Assessment is the first stage in the nursing process and is key to developing a care plan that is tailored to a patient's individual needs (Figure 1.1).

Figure 1.1 Assessment – the first stage in the process of planning patient care.

The purpose of assessment is to achieve the following:

• Obtain baseline data and track changes. On admission to hospital or on a first visit to the clinic, it is important to carry out a comprehensive assessment of the patient to establish a set of baseline data against which subsequent assessments can be compared and any changes indicating a deterioration or improvement in the patient's condition tracked.
• Early recognition of the critically ill or deteriorating patient. Identifying patients who are ‘at risk’ is key to initiating a rapid response from the medical emergency or rapid response team. ‘Track and Trigger’ (e.g. Alert® and other early warning systems) incorporate objective physiological and subjective criteria that can be used to support the nurse's decision about when to call the medical team for help and avert more serious patient emergencies (National Institute for Health and Clinical Excellence [NICE], 2007). If a Track and Trigger system has not been set up in the hospital, a nurse who is concerned about a patient should take urgent action and notify the medical team.
• Risk assessment. Assessment is the first step in preventing complications, the aim being to identify patients who are ‘at risk’ of developing complications associated with their healthcare problem, hospitalisation and reduced mobility. Key areas for risk assessment include pressure ulcers, infection, falls and constipation. Local hospital policy may include risk assessment tools as part of the admission procedure, for example the Braden, Waterlow and Norton scores to identify patients at risk of pressure ulcers and to activate an action plan and interventions to prevent pressure ulcers developing.
• Screening for health problems. Nursing assessment provides an ideal opportunity for health promotion and for screening patients for risk factors associated with obesity, cancer, cardiovascular disease, diabetes mellitus and other major Irish and UK health problems. It also provides the opportunity to screen for specific problems such as emotional distress or organisms important in infection control (e.g. methicillin-resistant Staphylococcus aureus [MRSA] and vancomycin-resistant Enterococcus [VRE]).
• Identify actual and potential problems and prioritise care. The patient's current problems (actual problems) and problems that could develop in the future (potential problems) need to be identified so that the care plan can be tailored to individual patient needs. Importantly, once the range of patient problems has been identified, care can be prioritised so that major problems are dealt with first.
• Care planning, tailored to individual patient needs. The purpose of assessment is not only to determine and document the patient's current condition, but also to provide evidence for the planning and provision of nursing care. Although standardised care plans are available in some units or hospitals, the nursing actions that are required to meet a patient's needs and problems should be tailored to take account of individual patient needs.
• Discharge planning. Patient assessment also includes the early identification of patients' needs for forward planning and organising the supports and community services necessary to facilitate a timely discharge from hospital. Recent trends indicate that patients' stay in hospital is shortening, the use of day surgery is increasing, and policies on early discharge and discharge planning are setting the standards for healthcare practice (Capelastegui et al. 2008; Saczynski et al. 2010; Shepperd et al. 2010). Although the reasons for a delay in discharging the patient home from hospital are multifactorial, patient assessment that includes information about the patient's home and social circumstances, family and community supports will help prevent problems arising from a poor knowledge of a patient's home situation or the support available, and will avert delays related to non-medical reasons.

Assessment frameworks

An important principle underpinning the nursing approach to patient assessment is that it is systematic, comprehensive and person-centred. Many of the assessment frameworks used in clinical practice are linked to nursing theories such as the activities of living (Roper et al. 2000) or the self-care deficit th...

Table of contents

• Cover
• Titles of related interest
• Title page
• Copyright page
• About the series
• Preface
• About the editors
• Contributors
• How to get the best out of your textbook
• About the companion website
• Part 1: Common Principles Underlying Medical and Surgical Nursing Practice
• Part 2: Adult Medical and Surgical Nursing
• Index