Assessing a patient is one of the key aspects of the nursing role, and you can expect to carry it out numerous times in your career. While the exact process will vary according to the setting and the type of patient, the following are the key points to bear in mind each time.
Get ready for the assessment
Every time you enter the room to meet a new patient, you need to be ready to carry out an assessment using all of the tools available to you. It means having the likes of a thermometer and stethoscope ready to check their vital signs immediately.
With experience, you’ll also begin to notice the subtle signs, like smells or posture, that make you immediately realize what could be happening. However, it’s important to not jump to conclusions and to carry out the assessment professionally every time.
It means taking a moment before entering the room to forget about your last patient or any personal issues that are on your mind. Correctly assessing the next patient is your immediate priority and what you want to focus your full attention on.
The need to build rapport with the patient
You need to bear in mind that patients may be worried, stressed, tired, and nervous about the assessment. Therefore, the first step is putting their mind at ease and getting them to trust you. Using the right professional yet caring attitude is vital from the very first second.
It means introducing yourself professionally to the patient and explaining what you’re going to be doing to assess them. You want to make them comfortable and build trust right away, so look them in the eye and ask open questions that are designed to get them to relax and talk to you.
This is where you need to use your communication skills to ask the right questions clearly and then pay close attention to the answers. If you don’t listen carefully, you could miss a crucial clue at this stage.
Check the patient’s medical history
The person’s history and background could be extremely useful in helping you see what has happened in the past and what needs to be done now. The likes of their history of surgeries, allergies, and medications could point you in the right direction, although you don’t want to jump to conclusions.
At this point, asking the right questions can help you work out what might be causing the current situation and what is behind any symptoms you’ve seen. Having a questionnaire to use in this situation could be a good idea, although as you gain more experience, you may find that you prefer to adapt your approach to each case.
If they’re living with a medical condition, they may have informed themselves about it, but don’t rely solely on what the patient tells you. Instead, this is just a starting point for your investigations, which could point you in the right direction.
Carry out a physical examination
Your next step is to carry out a physical examination of the patient. The work you’ve done with them so far may have given you an idea of what to focus on, but you’ll still want to keep an open mind as you examine them.
This sort of examination is likely to include taking their temperature, checking their respiratory and heart rates, and all of the other tests that let you see the patient’s vital signs. At this point, you will be relying on your knowledge of the different types of testing you will be relying on your knowledge of the different types of testing you learned when you were getting trained.
One of the most convenient ways of getting the knowledge needed for a nursing job is through a course to earn an online FNP certificate. Since this sort of program offers clinical placement opportunities, you can test the knowledge you’ve picked up in a real-life setting. This mixture of practical experience and learned skills will fill you with confidence for your first patient assessments.
Complete the paperwork
The paperwork involved in nursing roles might not be one of the most attractive aspects of them for you, but it’s a vital element that you need to get right. This is where you complete the details of the vital signs that you discovered when carrying out the physical examination.
It’s also where you add the subjective parts, such as the symptoms the patient mentions and anything relevant that you notice when speaking to them. This needs to be accurate and comprehensive, as the details you note following the assessment are vital to treating the person later.
Complete the diagnosis and recommended care or treatment
Once the previous steps are completed, you should now have enough information to analyze their symptoms and complete a diagnosis. If not, you’ll need to consider what other tests might be needed to allow you to reach a conclusion or whether the patient needs to be seen by a specialist.
An individual plan for the treatment or care of the person should be formulated at this point. It is where you may need to coordinate with other healthcare professionals or speak to their family members with the goal of making sure that the plan is followed and supported by the people who need to help the patient.
Your communication skills are going to be called into action once again. This is because it’s important that the patient and everyone else involved fully understand the diagnosis and what plan has been drawn up for them, along with the expected goals.
The future and ongoing assessments
Depending on the symptoms and the plan that you’ve created, you also need to work out when future assessments are to take place. These assessments will allow you to assess how the patient is responding to the treatment, which is one of the reasons why the paperwork that you completed earlier in the process is so vital.
Having done all this, you’ll feel confident that you’ve carried out your role effectively and given your patient the best possible care and attention by using a combination of technical and soft skills.