Nursing Education - Patient Assessment Skills

Nurses are trained to learn and apply patient assessment skills. These skills are the cornerstone of being a proficient nurse. The knowledge and procedures for developing these skills are learned in the first two years of nursing school and honed in clinical as the student nurse takes on a greater patient load. The "Standards of Care" that are the basis of nursing include the following:

Standard 1. Assessment

In an assessment the nurse must use all of his or her senses. These include hearing, touching, visual, and therapeutic communication. The cephalocaudal approach is most always used. In other words, assessing a patient from head to toe. The nurse must self aware to be able to conduct a thorough assessment. Data collection forms the basis for the next step in standards of care which is diagnosis. A nurse must have all the necessary equipment, such as a scale, tape measure, thermometer, sphygmomanometer, a stethoscope and pen light. The setting is also very important in doing an assessment. If a client is nervous or anxious they may not be as willing to answer questions that the nurse asks or to be examined. Obtaining a quiet environment is not always possible, especially in an emergency situation. Therefore, the nurse must be very observant, and try to get as much pertinent data as possible to formulate an nursing diagnosis For example, when doing an assessment on a client that is complaining of severe stomach pain, asking them what foods they last ate would give the nurse more pertinent information than asking them how many brothers or sisters they have.

Nursing Education - Patient Assessment Skills

Standard II. Diagnosis

A nursing diagnosis is not a medical diagnosis. A medical diagnosis would be the medical condition of "Diabetes". Whereas, a nursing diagnosis would be, "Altered Tissue Perfusion", related to decreased oxygenation of tissues as evidenced by a pulse oximetry of 92% , secondary to the medical condition of "Emphysema". A nursing diagnosis is a formal statement that relates to how a client reacts to a real or perceived illness. In making a diagnosis the nurse attempts to formulate steps to assist the client in alleviating and or mediating how they respond to real or perceived illness.

Standard III. Outcome Identification

In this process the nurses uses the assessment and diagnosis to set goals for the patient to achieve to attain a greater level of wellness. Such goals may simply be that the patient now comprehends the regime of testing their blood sugar, or perhaps a new mother gleans a sense of security now that she has been instructed in the correct method of breast feeding. The nurse must plan the goals that the client is to achieve around the clients ability. For instance, the goal that a client will walk normally after two days of having knee surgery is unrealistic, in the sense that the client's knee will not be completely healed. However, the goal that the client will be able to demonstrate the correct use of crutches, would be more realistic. This goal is also measurable, since the patient will be in the hospital and the nurse can teach and observe a return demonstration. Therefore, the goals or outcomes for the client must also be measurable.

Standard IV. Planning

The planning standard is designed around the clients activities while in the hospital environment. Therefore the nurse must plan to teach and demonstrate tasks when the patient is free to learn. This would involve administering pain medication prior to learning to walk with crutches or waiting until after a patient has finished a meal before teaching on how to use a syringe. The atmosphere should be conducive for the client to learn.

Standard V. Implementation

This standard requires that the nurse put to the test the methods and steps designed to help the client achieve their goals. In implementation, the nurse performs the actions necessary for the client's plan. If teaching is one of the goals then the nurse would document the time, place, method and information taught.

Standard VI. Evaluation

Evaluation is the final standard. In this step the nurse makes the determination whether or not the goals originally set for the client have been met. If the nurse concludes that the goal or goals have not been met, then the plan has to be revised and documented as such. Goals therefore should be timely and measurable. If the client's goal was to use crutches successfully, and the client was able to perform a repeat demonstration for the nurse, then the goal was met.

The above standards are the cornerstone of the nursing profession. These standards take time and experience to learn and to implement. Experience is the best teacher, and a nurse should continuously strive for excellence in their care of patients, and recognizing how to help patients achieve a higher level of physical and emotional wellness.

Learn more about nursing education at The NET Study Guide.

Nursing Education - Patient Assessment Skills
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The nursing entrance test study guide provides nurses the assistance they need with the nursing entrance test. The nursing study guide helps nurses. Visit nurseslearningcenter.com for more information.

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Importance of Patient Education in the Hospital Setting

Shorter hospital stays related to cost containment with managed care, make another area important. That is patient education.

In hospitals who set the highest standards and have the budgetary ability for its support,there is a patient education department or at least the ability to provide to patient educational material. In most hospitals the nursing standards includes the provision of education to patients and families along with the appropriate literature related to their illness and incorporates this into nursing care.

Goal Setting

Budget cutting that excludes the process of patient education falls short in meeting the needs of patients and fails miserably in our health care system.

Importance of Patient Education in the Hospital Setting

What does this mean to a patient? It means from the time you enter a hospital until and including their discharge, there should be ongoing information provided.

It begins with instruction on the use of your call bell, with essential confirmation that you understand by feedback to your nurse. All the questions you are asked provide healthcare staff of important information, such as any allergies you may have. A wrist band should include your name and allergies.

Every procedure that is done to you as a patient should be preceded by an explanation as to what it is evaluating and how it is done.

Everytime a medication is administered to you, its name and action should be explained along with the provision of printed educational material.

When there is a change in your condition requiring a new plan of care you and your family should have input into it.

If you or your family member needs additional support not available through the hospital such as your community or religious support, they can be notified. Patient confidentiality prevents the hospital from making your stay there public.

Do not fear the hospital environment, but be alert to anything unusual, if your medication looks different or if you are suddenly being whisked off for a test you have not been advised of, notify your nurse. Make sure the hospital staff uses your last name in your care with frequent checks of your ID band.

When your injury or illness causes you pain. It is best to request medication before it becomes too severe as it will take time for the nurse to visit you and then obtain it for you. They should be using a pain scale to assess your pain and to be sure your pain relief is adequate.

Remember your nurse and your doctor should also be your teachers.

It is critical that any sudden pain or distress, such as chest pain or shortness of breath,be addressed promptly and it is most appropriate to call out for help if there is a delay in answering your call bell.

At the time of your discharge from the hospital, which can be overnight or a day or two.You should be given in writing discharge instructions with a verbal review for you and your family It should include new medications how they are to be taken and matching literature for reinforcement. It should advise diet and activity level, as well as return visit with doctor. There should be phone numbers and instructions for contact in the event of any complications.

In this harried time in health care try to understand the hospital has to triage in the emergency room,that means that the most critically ill patient must be seen first and often that means you must wait your turn. For non emergency type health problems it is best to use the office visit.

Ask questions freely, the harried staff will appreciate this and will give you clarifications rather then having things come undone through misunderstandings.

We are all part of this system as it is today,those who care for you also get ill and experience the same frustrations as everyone else. But, with all its imperfections, we have made great advances in healthcare and most of us will have a better quality of life because of it.

Importance of Patient Education in the Hospital Setting

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