The Royal Marsden Hospital Manual of Clinical Nursing Procedures - Lisa Dougherty [39]
Is the patient pain free at rest and/or on movement?
Is the pain a primary complaint or a secondary complaint associated with another condition?
What is the location of the pain and does it radiate?
When did it begin and what circumstances are associated with it?
How intense is the pain, at rest and on movement?
What makes the pain worse and what helps to relieve it?
How long does the pain last, for example, continuous, intermittent?
Ask the patient to describe the character of pain using quality/sensory descriptors, for example, sharp, throbbing, burning.
For further details regarding pain assessment, see Chapter 9.
2 Activity and exercise
Respiratory
Respiratory pattern monitoring addresses the patient’s breathing pattern, rate and depth.
In this section it is also important to assess and monitor smoking habits. It is helpful to document the smoking habit in the format of pack-years. A pack-year is a term used to describe the number of cigarettes a person has smoked over time. One pack-year is defined as 20 manufactured cigarettes (one pack) smoked per day for 1 year. At this point in the assessment, it would be a good opportunity, if appropriate, to discuss smoking cessation. A recent meta-analysis indicates that if interventions are given by nurses to their patients with regard to smoking cessation the benefits are greater (Rice and Stead 2008).
Does the patient have any difficulty breathing?
Is there any noise when they are breathing such as wheezing?
Does breathing cause them pain?
How deep or shallow is their breathing?
Is their breathing symmetrical?
Does the patient have any underlying respiratory problems such as COPD, emphysema, tuberculosis, bronchitis, asthma or any other airway disease?
For further details, see Chapter 10.
Cardiovascular
A basic assessment is carried out and vital signs such as pulse (rhythm, rate and intensity) and blood pressure should be noted. Details of cardiac history should be taken for this part of the assessment. Medical conditions and previous surgery should be noted.
Does the patient take any cardiac medication?
Does he/she have a pacemaker?
For further information, see Chapter 12.
Physical abilities – personal hygiene/mobility/toileting – independence with the activities of daily living
The aim during this part of the nursing assessment is to establish the level of assistance required by the person to tackle activities of daily living such as walking and steps/stairs. An awareness of obstacles to safe mobility and dangers to personal safety is an important factor and part of the assessment.
The nurse should also evaluate the patient’s ability to meet personal hygiene, including oral hygiene, needs. This should include the patient’s ability to make arrangements to preserve standards of hygiene and the ability to dress appropriately for climate, environment and their own standards of self-identity.
Is the patient able to stand, walk and go to the toilet?
Is the patient able to move up and down, roll and turn in bed?
Does the patient need any equipment to mobilize?
Has the patient good motor power in their arms and legs?
Does the patient have any history of falling?
Can the patient take care of their own personal hygiene needs independently or do they need assistance?
What type of assistance do they need: help with mobility or fine motor movements such as doing up buttons or shaving?
It might be necessary to complete a separate manual handling risk assessment
For further information, see Chapters 7 and 9.
3 Elimination
Gastrointestinal
During this part of the assessment it is important to determine a baseline with regard to independence.
Is the patient able to attend to their elimination needs independently and is he/she continent? Are bowel movements within the patient’s own normal pattern and consistency?
What are the patient’s normal bowel