In carrying out a patient assessment, important components such as patient health history and physical health should be examined using a holistic approach. A nurse would require information from the patient, friends and family, diagnostic tests and patient medical records (Jarvis, 2004). A comprehensive assessment should include a detailed survey of physical signs such as weight and height, an assessment of the patient’s body systems and organs. On the other hand, a priority assessment is a short evaluation, normally completed within 5 minutes, which gives an overall evaluation of the patient. However, a more in-depth assessment of the patient is required to make a diagnosis.
First Chart Case
The patient’s chief complaint is an itchy rash on the right side. Thus, the problem presented here is that of a painful itchy rash. A focused or selective assessment of the patient’s medical history will give information that may prompt an evaluation of other body organs or systems (Fraser, 2005). Moreover, using PQRSTA approach, both objective and subjective data can be collected to inform the assessment. Subjective data is the information provided by the patient to the assessor and is based on the patient’s perception. On the other hand, objective data are data based on the nurse’s observations (Kozier et al., 2004). Objective data, unlike subjective data is measurable and verifiable.
It is evident that the assessment did not involve a systematic organized approach that covers all aspects of the patient’s health status. Aspects such as functional, physiological and psychosocial health of the patient were not covered in this assessment. For the nurse, it is important that to make an inference about the likely relationship between the irritation and Neosporin applied to bring relief. Thus, more information/data should be collected with regard to this finding.
The nurse should collect more focused data about the rash. He/she should find out if the rash is a result of body reactions, when it started, does it spread, whether the rash is present in other parts of the body and whether the patient has any known allergies. However, the clinical problem identified does not appear result to any clinical manifestations as the patient does not have fever nor stomach upsets.
Second Chart Case
The problem presented (chief complaint) is a cough for which the patient is admitted to the ER. More focused assessment has revealed information related to the complaint. A priority assessment i.e. an assessment of the patient’s overall health status uncovers that diminished lung sounds, wheezing and crackles in middle right lobe; this data is relevant to this case, and the nurse should consider them abnormal. The findings of the assessment then should be compared to baseline (chart) findings (Fitzpatrick, & Shinners, 1996). For objective data, information such as patient activity, position of the patient, skin color, as well as signs of discomfort (i.e. dyspnea, as in this chart case) should be noted. The findings from this case, i.e. lung sounds diminished at the base and the faint crackles in the right middle lobe and wheezing needs further examination such as auscultation. Besides cough and wheezes, the nurse should look out for common signs of respiratory dysfunction such as chest pain/discomfort, production of sputum and dyspnea. This would be important in making a diagnosis regarding the pulmonary condition affecting the patient.
The comparison of the data collected with baseline data will be important in the assessment of the health status of the patient. Changes in body temperature, BP, HR could indicate inflammatory response to an infection or other stressors, which would need further assessment. Subjective data is also important. Patient anxiety, discomfort, feelings or worries comprise the subjective data, which should be compared with the objective data.
Clinical Reasoning vs. Nursing Assessment
Clinical reasoning guides healthcare professionals including nurses in clinical decision-making process. Clinical reasoning involves assessment, assimilation, retrieval of healthcare information, which is vital in making accurate diagnosis of a condition (Spain, et al., 2004). The term refers to the cognitive processes that nurses use to evaluate patient issues and arrive at a logical decision (Spain, et al., 2004). Clinical reasoning is one distinctive attribute of nurses that lacks in other ancillary healthcare professionals. Moreover, clinical reasoning is crucial in the present healthcare industry as it enables nurses to be independent, accountable and responsible for patient care.
Advances in technology have resulted to improved healthcare delivery, shortened hospital stays and improved patient acuity. Nevertheless, the same technological advances have made healthcare delivery more complex, while working in risky or uncertain conditions is the norm of nursing practice (NONPF, 2006). Critical decision-making skills are therefore important to avoid medical errors and improve patient outcomes. Clinical reasoning components include thinking (cognition), reflective, learnt skills/knowledge as well as context of the patient within the care settings.
On the other hand, nursing assessment is the process of collecting, verifying and analyzing information regarding a patient. Nursing assessment starts soon after the patient is admitted into a healthcare facility, and goes on throughout the entire treatment period. The assessment process covers various domains that are interdependent are help in developing a holistic picture about the health of the patient. These include physiologic (biological/functional aspects), psychological (cognitive and emotional characteristics) and social (interpersonal relationships).
Unlike clinical reasoning, nursing assessment generates a database of information specific to the patient, from which the nurse can identify the health status of the patient; develop and interpret an appropriate plan of care; make appropriate decisions regarding the nursing interventions for a particular diagnosis; intervenes; monitors changes in patient’s health; and keeps records to enable the patient attain optimal health (Murphy, 2004). Nursing assessment begins with an assessment of patient’s medical history and physical assessment, home environment and interpersonal relationships. After the physical assessment, a health history (biographic data, past history, allergies, family health history and cultural believes among others) is conducted. While clinical reasoning does not necessarily involve consultation with family, friends and paraprofessionals who may have interacted with the patient, nursing assessment involves consultations to make determine recent changes in health status of the patient.
Patient Case Situation
Patient problems are identified from the data collected by nursing assessment. Nursing role is continuously changing as healthcare environment becomes shrouded with multiple risks, uncertainty and complexity due to advancement in technology and cormobidities (College of Licensed Practical Nurses of BC, 2005). This requires knowledge in patient assessment and clinical reasoning; an important component in nursing role that ensures safety and quality care delivery. Thus, it is the professional responsibility of the nurse to acquire all the necessary competencies. As an advanced practice nurse (APN), I believe that the required competencies can be obtained during formal training/education, in-service programs or life-long learning. I also believe that skills in clinical reasoning and patient assessment can be achieved through reflective practice, regular feedback from completed assessments and continued learning.
One particular case I encountered a year ago that impacted my approach towards patient assessment was that of Mr. Bill. Mr. Bill was a 53-year old patient, who was under my care. His admission was due to an episode of dyspnea, for which I examined the vital signs. He said that he woke up that day with shortness of breath, which made him panic. He reported that he smoked for over 30 years but quit six months ago, after his brother died of lung cancer. The diagnosis showed that Mr. Bill has emphysema.
Further examination and assessment established the following revelations; non-productive cough, fatigues, shortness of breath, expression of fear, restlessness, irritability, trembling and sweating. A further focused assessment revealed that Mr. Bill is worried that he might die of lung cancer like his brother; lives with a 14-year old grandson; is worried of being sacked due to many sick off days; cannot work continuously without resting. The focused assessment enabled me to uncover patient problems like activity intolerance, health maintenance that were important in the final diagnosis. Many factors may affect nursing competency in clinical reasoning and patient assessment. Thus, focused assessment and self-evaluation enhance competent nursing practice.
References
Fitzpatrick, J. B. & Shinners, M. C. (1996). How to make assessing patients as easy as ABC.
Nursing, 26(8), 51.
Fraser, H. (2005). Medical Nursing Assessment and Flow Sheet. Burnaby, BC: Author.
Jarvis, C. (2004). Physical examination and health assessment. (4th ed.). New York: Saunders
Kozier, B., Erb, G., Berman, A.J., Burke, K., Bouchal, D.S. & Hirst, S. P. (2004). Fundamentals of nursing: The nature of nursing practice in Canada. (1sted.). Toronto: Prentice Hall.
Murphy, J.I. (2004). Using focused reflection and articulation to promote clinical reasoning: an
evidence-based teaching strategy. Nursing Education Perspectives, 25(5), 226–231
National Organization of Nurse Practitioner Faculties (NONPF) (2006). Domains and Core
Competencies of Nurse Practitioner Practice. Retrieved on January 13, 2013 from
Spain, M.P. et al. (2004). Educating advanced practice nurses for collaborative practice in the
multidisciplinary provider team. Journal of the American of Nurse Practitioners, 6(11), 535-546
