The Royal Marsden Hospital Manual of Clinical Nursing Procedures - Lisa Dougherty [36]
Problems with the gastrointestinal system.
Elimination Excretory patterns (bowel, bladder, skin).
Excretory problems such as incontinence, constipation, diarrhoea and urinary retention may be identified.
Activity and exercise The activities of daily living requiring energy expenditure, including self-care activities, exercise and leisure activities.
The status of major body systems involved with activity and exercise is evaluated, including the respiratory, cardiovascular and musculoskeletal systems.
Sleep and rest The person’s sleep, rest and relaxation practices.
Dysfunctional sleep patterns, fatigue, and responses to sleep deprivation may be identified.
Cognitive and perceptual ability The ability to comprehend and use information.
The sensory functions, neurological functions.
Perception/concept of self The person’s attitudes toward self, including identity, body image and sense of self-worth.
The person’s level of self-esteem and response to threats to their self-concept may be identified.
Stress and coping The person’s perception of stress and its effects on their coping strategies.
Support systems are evaluated, and symptoms of stress are noted.
The effectiveness of a person’s coping strategies in terms of stress tolerance may be further evaluated.
Roles and relationships The person’s roles in the world and relationships with others.
Satisfaction with roles, role strain or dysfunctional relationships may be further evaluated.
Sexuality and reproduction The person’s satisfaction or dissatisfaction with sexuality patterns and reproductive functions.
Concerns with sexuality may be identified.
Values and belief The person’s values, beliefs (including spiritual beliefs) and goals that guide their choices or decisions.
(Adapted from Gordon 1994)
In the middle working phase, various techniques can be employed to assist with the flow of information. Open questions are useful to identify broad information that can then be explored more specifically with focused questions to determine the nature and extent of the problem. Other helpful techniques include restating what has been said to clarify certain issues, verbalizing the implied meaning, using silence and summarizing (Morton 1993). It is important to recognize that there may be times when it is not possible to obtain vital information directly from the patient; they may be too distressed, unconscious or unable to speak clearly, if at all. In such situations, appropriate details should be taken from relatives or friends and recorded as such. Effort should equally be made to overcome language or cultural barriers by the use of interpreters.
The end phase involves a further summary of the important points and an explanation of any referrals made. In order to gain the patient’s perspective on the priorities of care and to emphasize the continuing interest in their needs, a final question asking about their concerns can be used (Alfaro-Lefevre 2002). Examples include: ‘Tell me the most important things I can help you with’, ‘Is there anything else you would like to tell me?’, ‘Is there anything that we haven’t covered that still concerns you?’ or ‘If there are any changes or you have any questions, do let me know’.
Box 2.4 is a summary of the types of assessment.
Box 2.4 Types of patient assessment
Mini assessment
A snapshot view of the patient based on a quick visual and physical assessment. Consider patient’s ABC (airway, breathing and circulation), then assess mental status, overall appearance, level of consciousness and vital signs before focusing on the patient’s main problem.
Comprehensive assessment
An in-depth assessment of the patient’s health status, physical examination, risk factors, psychological and social aspects of the patient’s health that usually takes place on admission or transfer to a hospital or healthcare agency. It will take into account the patient’s previous health status prior to admission.
Focused assessment
An assessment of a specific condition, problem, identified risks or assessment of care; for