The Royal Marsden Hospital Manual of Clinical Nursing Procedures - Lisa Dougherty [41]
What is the condition of the patient’s oral cavity?
(Perdue 2005)
5 Skin
A detailed assessment of a patient’s skin may provide clues to diagnosis, management and nursing care of the existing problem. A careful skin assessment can alert the nurse to cutaneous problems as well as systemic diseases. In addition, a great deal can be observed in a person’s face, which may give insight to his or her state of mind.
Does the patient have any wounds or sore places on their skin?
Does the patient have any dry or red areas?
Furthermore, it is necessary to assess whether the patient has any wounds and/or pressure sores. If so, you would need to complete a further wound assessment. For further information about wound care, see Chapter 15.
6 Controlling body temperature
This assessment is carried out to establish baseline temperature and determine if the temperature is within normal range, and whether there might be intrinsic or extrinsic factors for altered body temperature. It is important to note whether any changes in temperature are in response to specific therapies (e.g. antipyretic medication, immunosuppressive therapies, invasive procedures or infection (Bickley 2007)). White blood count should be recorded to determine whether it is within normal limits. See Chapters 11 and 12 for further information.
Is the patient feeling excessively hot or cold?
Have they been shivering or sweating excessively?
7 Sleep and rest
This part of the assessment is carried out to obtain sleep and rest patterns and reasons for variation. Description of sleep patterns, routines and interventions applied to achieve a comfortable sleep should be documented. The nurse should also include the presence of emotional and/or physical problems that may interfere with sleep.
Does the patient have enough energy for desired daily activities?
Does the patient tire easily?
Has he/she any difficulty falling asleep or staying asleep?
Does he/she feel rested after sleep?
Does he/she sleep during the day?
Does he/she take any aids to help them sleep?
What are the patient’s normal hours for going to bed and waking?
8 Stress and coping
Assessment is focused on the patient’s perception of stress and on his or her coping strategies. Support systems should be evaluated and symptoms of stress should be noted. It includes the individual’s reserve or capacity to resist challenge to self-integrity, modes of handling stress. The effectiveness of a person’s coping strategies in terms of stress tolerances may be further evaluated (adapted from Gordon 1994).
What are the things in the patient’s life that are stressful?
What do they do when they are stressed?
How do they know they are stressed?
Is there anything they do to help them cope when life gets stressful?
Is there anybody who they go to for support?
9 Roles and relationships
The aim is to establish the patient’s own perception of the roles and responsibilities in their current life situation. The patient’s role in the world and their relationships with others are important to understand. Assessment in this area includes finding out about the patient’s perception of the major roles and responsibilities they have in life, satisfaction or disturbances in family, work or social relationships. An assessment of home life should be undertaken which should include how they will cope at home post discharge from hospital and how home will cope while they are in hospital, for example dependants, animals or children and if there are any financial worries.
Who is at home?
Are there any dependants (include children, pets, anybody else they care for)?
What responsibilities does the patient have for the day-to-day running of the home?
What will happen if they are not there?
Do they have any concerns about home while they are in hospital?
Are there any financial issues related to their hospital stay?
Will there be any issues related to employment or study while they are in hospital?
10 Perception/concept of self
Body image/self-esteem