Patient Assessments in Nursing Practice

The Importance of Assessing a Patient in Its Entirety

“Knowing the patient” is an important concept in nursing and healthcare. It is not enough to have some general facts (Kelley, Docherty, & Brandon, 20114). It is necessary to analyze the situation and assess a patient in its entirety. To assess a patient’s means to communicate with a person and investigate their medical history in order to clarify the causes of health problems and the possible challenges in treatment (Nield-Gehrig & Willimann, 2013). When people address a hospital or a medical center, they expect to find relief of pain and end of their sufferings. Physical examination and assessment are the first steps that should be taken by the medical staff in order to provide a patient with confidence and demonstrate their readiness to help. An assessment helps to comprehend the patient’s needs and choose the best and the most appropriate diagnosing and treatment methods. Sharing personal information and physical contact provide nurses and doctors with a chance to identify the major problems and choose the correct direction. It is wrong to neglect this process. Besides, every mistake made at this stage has a crucial impact on patients and even doctors and nurses, who could lose their jobs because of wrong or incomplete assessment.

Evidence-Based Assessment, Types of Assessments

Evidence-based assessment (EBA) is a part of evidence-based practice that promotes the use of thorough and judicious evidence that is crucial to making decisions about the type of care and help that could be offered to a certain patient. This type of assessment promotes the integration of individual clinical expertise with external clinical research and patient’s values. In other words, EBA is based on research and theory that help to choose assessment domains in regards to the guidelines when diversity and personal interests cannot be ignored (Benuto & Leany, 2014). In this kind of assessment, nurses or other medical staff have to gather enough information about a patient and combine it with general facts and aspects. For example, it is possible to use observations, interviews, or portfolios to gather the required portion of information from a direct source. In addition, it is possible to review recent journals and investigate what other professors and experts know on the chosen topic. Though this assessment could take much time, its results are more effective in comparison to other assessments from a theoretical point of view.

Functional Assessment: Why It Is Important in Healthcare

In health care, functional assessment is one of the possible reviews that could be offered to patients when it is necessary to check a person’s mobility, transfer skills, and regular activities such as self-care or communication. It is usually used to identify the normal indexes of patients and create a kind of baseline with the help of which it is possible to develop further diagnoses, treatments, and rehabilitation outcomes. The evaluation of therapeutic interventions is impossible without functional assessment. This assessment includes the assessment of mental status, physical examination, patient’s functional status, pain factors, and even social or economic status of a patient (Mueller, Hamilton, Rodden, & DeHeer, 2016). It cannot be neglected in health care because it provides nurses and doctors with an opportunity to comprehend what they can expect from their work and if it is possible to help their patients at the moment of functional assessment.

Assessing Techniques according to Developmental Age

As a rule, assessing techniques vary in accordance with the developmental age of a patient. For example, children usually undergo physical examinations through palpations and observations. Toddlers, adolescents, and young adults, who could talk, may share their personal information and discuss their problems aloud. Still, the younger the developmental age of a patient is, the more at risk this patient could actually be because of the possibility of long-term problems and the inability to develop time-lapsed assessments (Thompson, 2013). Assessment of adults and older people should be based on evidence and systematic reviews because statistics and facts could improve nurse’s or doctor’s understanding of patients’ problems and expectations. Nowadays, many doctors and parents find it necessary to rely on theories and literature to diagnose children instead of focusing on the actual symptoms and evidence. Therefore, such techniques as physical examination, functional assessments, and X-rays could be used by doctors to diagnose their patients in a proper way.

The Clinical Setting, General Approach for Examination and Best Way of Implementation

In the clinical setting, a physical examination is a general approach and the best way for doctors to diagnose people and provide them with effective treatment. Physical examination is a fundamental practice that cannot be ignored because it clinicians to sort out the disease’s causes and decrease the level of pain (Waldman, 2014). For its better implementation, a clinician should have a free place (a room), appropriate equipment, and enough time to observe all changes or unusual conditions that could be used to diagnose a patient. It is necessary, to begin with gathering information on the patient. Then, a physical examination takes place on the basis of the observations and medical history. Finally, a physical examination is crucial for a therapist because it provides people with time to develop a rapport and promote the portion of healing that is required for a patient.

References

Benuto, L.T., & Leany, B.D. (2014). Guide to psychological assessment with African Americans. Prescott Valley, AR: Springer.

Kelley, T., Docherty, S., & Brandon, D. (2013). Information needed to support knowing the patient. Advanced in Nursing Science, 36(4), 351-363.

Mueller, K., Hamilton, G., Rodden, B., & DeHeer, H.D. (2016). Functional assessment and intervention by nursing assistants in hospice and palliative care inpatient care setting: A quality improvement pilot study. American Journal of Hospice and Palliative Medicine, 33(2), 136-143.

Nield-Gehrig, J.S., & Willimann, D.E. (2013). Patient assessment tutorials: A step-by-step procedures guide for the dental hygienist. Philadelphia, PA: Lippincott Williams & Wilkins.

Thompson, P.S. (2013). The school psychology licensure exam guide (2nd ed.) New York, NY: Springer.

Waldman, S.D. (2014). Atlas of international pain management. Philadelphia, PA: Elsevier Health Sciences.