The nursing of patient assessments

Modified: 3rd May 2017
Wordcount: 927 words

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The following information will describe what the nursing process is and how a nurse assesses a patient by using effective communication skills and maintaining a safe environment for the patient in the hospital setting and on discharge from the hospital to the patient’s usual place of residence.

The nursing process is an essential part of nursing care. It is an evolving circle of events that should be continued throughout the patients stay in hospital. It starts with the assessment of the patient, this is when all the initial observations of the patient are done and a diagnosis of the illness is found. Then the nursing team has to plan the best and safest treatment plan for the patient’s end goal. Once the treatment plan has been agreed how the goal will be met for the patient the plan is evaluated to see how well the goal has been achieved or not and if the treatment has to be continued or changed. This is a continuing circle as the patient is reassessed and treatment plan is changed depending on the evaluation outcome. This continues throughout the patients stay in hospital. (Siviter, 2004)

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The nurse should assess the patient by using effective communication skills. Communication can be measured in different ways, these are verbal and non verbal, written, and body language. This can be from the nurse to the patient or the patient to the nurse. Verbal communication can be misunderstood if the non verbal communication that goes along with it doesn’t match what is being said. This can be when the patient saying that they are feeling fine but is holding a part of their body as to protect it from pain. So the nurse has to observe that these things match each other. They way things are said can also be misinterpreted, so the tone and volume have to be correct, remembering to know if the patient has any hearing difficulties. The way things are wrote down and the way that they are read can also be different depending on how clear and understandable it is to other people. Things that are wrote down can also be mistaken as other things due to spelling mistakes, abbreviations and poor hand writing skills. To overcome this, the nurse should use dictionaries if unsure of correct spelling and not to use abbreviations that other people won’t know, nursing staff on the ward might know what the abbreviations mean but new staff won’t and mistakes can be made from that. The usage of body language can either intimidate a patient if the nurse seems to be too standoffish this can be when the nurse has their arms folded or hand in pockets, the patient may think the nurse isn’t interested in them. The patient might also feel intimidated if the nurse seemed too inviting, this is when they have an open stance like sitting face on to the patient with legs opened and being unnecessary touchy with the patient.

For the nurse to maintain the safety of the environment for the patient in the hospital the nurse needs to ensure that all the equipment that will be available to the patient during their stay is in full working order and that the patient understands how to work it. This can be from the patient having a three wheeled walking frame but not getting the correct instructions on how to use it and not putting the brakes on when they are releasing themselves from it causing the wheels to move and the patient can potentially fall. It can go more serious than that and can be that the nurse has left sharps on the patients bed leaving them in danger of getting a needle stick injury from their own used needle. If the patient is at risk from pressure ulcers then they should be using an air mattress and a turning chart so the staff is aware of the last turn time and onto what side. If this is used correctly then the patient may not gain a pressure ulcer while in hospital. It is also an important duty of the nurse to help stop infection in the ward spreading to the other patients. This is done by ensuring the nurse uses proper infection chain breaking procedures. The nurse needs to wash their hands in between each patient either with hot soapy water or alcohol gel, although this can only be used up to 5 times before the nurse should wash with soap and water. The nurse should also be using a new set of gloves and aprons between each patient and disposing them in the patient’s bin.

Once the patient is ready to go back home the nurse needs to make sure that there is input for the other members of the multi disciplinary team involved in the patient’s aftercare. The nurse will assess the patient and tell the other members of the team what they need for this. The nurse should also ensure that the patient has the aftercare required to help with the recovery process. (Baillie, 2001)

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This points out the importance of the nursing process and that it is carried out efficiently and effectively. This ensures that the patient gets the best and correct care while in hospital and that it is carried out on the fastest occasion that is needed for the patient. Effective communication is a large part of the nurse’s role as this shows the patient that they are empathetic and concerned about them, this puts the patient at ease and they might be more truthful about their initial assessment. Patients go into hospital to get better as quick as possible, this is only able if the nurse maintains a safe environment in the ward and ensures all equipment is up to date and the patient has the training and is comfortable using it.

 

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