Physical Assessment is the physical examination of a patient to collect objective data.Use your stethoscope. You will look or observe ,and assess your patient from head to toes.This will help you to determine patient conditions, help you to determine the nursing Diagnosis and help the nurse in the Plan of care. For example you admitted a diabetes ketoacidosis patient but did not know that she has a stage 111 pressure ulcer on her sacrum because it was not communicated to you by the Emergency room nurse or was not communicated to you by the ICU nurse.If you didn’t do your physical assessment you will not know. Sometimes some nurses will not tell you because they don’t know or because they did not do their physical assessment and not documented or communicated to them.It is good to perform a comprehensive physical assessment which will identify health and illness of the patient. As a Registered nurse it is important to select important aspects of physical assessment. While the nurse physical assessment focuses on the patients ability to function .The Physician physical assessment focus mainly on identification of Pathophysiology and the cause and the treatment regimen for the disease process. In the nursing physical assessment for example a patient with CVA, the nurse want to find out if patient can understand and communicate basic command.And if patient can perform activities of daily living.
So having identify the problems patient can be properly taken care of. While patient is in the hospital medications are given as ordered by the doctor ( Crushed medication or given whole ,one medication at a time) Nursing assistant to help with feeding while patient is sitting in upright position.
Physical assessment is for data collection.
The doctor writes the order for Physical therapy evaluation and treatment. Case manager for placement to SNF.And Speech therapist for swallow evaluation to make sure that patient can swallow before feeding the patient.
NURSING PROCESS :
These include the following below.
Assessment :Assess patient, physical assessment, patient history, and medical records. These are objective findings. Data are collected by observation, interview and physical assessment.
Diagnosis :Look at patient data analyze it,and interpret it.What do you think?.You now formulate and validate nursing diagnoses. In that nursing diagnoses setup priorities to the plan of care.
Planning : As a nurse you write down your goals. So what strategy do you develop to take care of the problem?. What measures are taken to achieve this plan of care for the patient. Patient came with pain .Your goal will be for the pain to be absent or reduction in pain.
Implementation: This is where you implement the plan of care.If it is not good enough, it can be modified. In implementation you are implementing the plan of care- goal.
Evaluation. At this stage as a Registered nurse you measure how well the patient has done. If patient has not done well, re-evaluate the plan and make changes, if it is not working for your patient.
What is your understanding of Nursing process?.
What is the purpose of patient assessment?.
Answer: We do patient assessment so that we can determine the kind of care that will be required to meet the patient initial needs and further needs as her or his condition changes in response to care.Assessment is individualized and are based on patient needs. Every facility is different so adhere to the policy and procedures of your facility.
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