The Royal Marsden Hospital Manual of Clinical Nursing Procedures - Lisa Dougherty [40]
Does the patient have any underlying medical conditions such as Crohn’s disease or irritable bowel syndrome?
Does the patient have diarrhoea or is he/she prone to or have constipation?
How does this affect the patient?
Genitourinary
The assessment is focused on the patient’s baseline observations with regard to continence/incontinence. It is also important to note whether there is any penile or vaginal discharge or bleeding.
Does the patient have a urinary catheter in situ? If so, list the type and size. Furthermore, note the date the catheter was inserted and/or removed. Urinalysis results should also be noted here.
How often does the patient need to urinate? (Frequency)
How immediate is the need to urinate? (Urgency)
Do they wake in the night to urinate? (Nocturia)
Are they able to maintain control over their bladder at all times? (Incontinence – inability to hold urine)
See Chapter 6 for further information.
4 Nutrition
Oral care
As part of the inpatient admission assessment, the nurse should obtain an oral health history that includes oral hygiene beliefs, practices and current state of oral health. During this assessment it is important to be aware of treatments and medications that affect the oral health of the patient.
If deemed appropriate, use an oral assessment tool to perform the initial and ongoing oral assessment.
During the admission it is important to note the condition of the patient’s mouth.
Lips – pink, moist, intact
Gums – pink, no signs of infection or bleeding
Teeth – dentures, bridge, crowns, caps
For full oral assessment, see Chapter 9.
Hydration
An in-depth assessment of hydration and nutritional status will provide the information needed for nursing interventions aimed at maximizing wellness and identifying problems for treatment. The assessment should ascertain whether the patient has any difficulty eating or drinking. During the assessment the nurse should observe signs of dehydration, for example dry mouth, dry skin, thirst or whether the patient shows any signs of altered mental state.
Is the patient able to drink adequately? If not, please explain why not.
How much and what does the patient drink?
Note the patient’s alcohol intake in the format of units per week and the caffeine intake measured in the amount of cups per day.
Nutrition
A detailed diet history provides insight into a patient’s baseline nutritional status. Assessment includes questions regarding chewing or swallowing problems, avoidance of eating related to abdominal pain, changes in appetite, taste or intake, as well as use of a special diet or nutritional supplements. A review of past medical history should identify any conditions and highlight increased metabolic needs, altered gastrointestinal function and the patient’s capacity to absorb nutrients.
What is the patient’s usual daily food intake?
Do they have a good appetite?
Are they able to swallow/chew the food – any dysphagia?
Is there anything they don’t or can’t eat?
Have they experienced any recent weight changes or taste changes?
Are they able to eat independently?
(Arrowsmith 1999, DH 2005, Malnutrition Advisory Group 2000)
For further information, see Chapter 8.
Nausea and vomiting
During this part of the assessment you want to ascertain whether the patient has any history of nausea and/or vomiting. Nausea and vomiting can cause dehydration, electrolyte imbalance and nutritional deficiencies (Marek 2003), and it can also affect a patient’s psychosocial well-being. They may become withdrawn, isolated and unable to perform their usual activities of daily living.
Assessment should address questions such as:
Does the patient feel nauseous?
Is the patient vomiting? If so, what is the frequency, volume, content and timing?
Does nausea precede vomiting?
Does vomiting relieve nausea?
When did the symptoms start? Did they coincide with changes in therapy or medication?
Does anything make the symptoms better?
Does anything make the symptoms worse?
What is the effect of any current or past antiemetic