 Assessment is one of several steps involved in the process of nursing. Patients are individuals. Diseases and disabilities are unique. And so must be the plan of care. No textbook solution can apply 100% of the time. Instead, an individualized and comprehensive plan of health care must be developed for every patient. A careful and thorough assessment is based on an analysis of information from a detailed health history, a physical examination, laboratory data, and a review of the patient's medical record. Such an assessment can then be translated into the patient's unique needs and serve as a basis for care planning. And so what we would like to do today is to try to get a complete medical history and do a physical examination and more laboratory studies so we can start from there. Of all the tools available to the nurse, verbal encounters are probably the single most valuable method to acquire data for assessing the patient's needs. When they told you you had it. I'm like anybody, I just don't like it. No, I really, I really don't feel like I'll have it. Patient response varies with each individual. The nurse must observe and adopt a technique early in the interview to best elicit pertinent information from the patient. You think of anything else about your past illnesses that you think would be important for me to know? No, I really think I've had it. Preparatory to the initial interview, the patient's medical records and reports should be carefully reviewed to familiarize the nurse with any data already available on the patient. Welcome the patient by name and appropriate title. Specialist wish? Yes. I'm Major Spine. Good morning. Yes, ma'am. A relaxed, unhurried approach should be used. A private area free from interruption and distraction should be provided for the interview. Physical arrangement of the interview area should enhance ease of listening, responding, and observation of nonverbal responses. Explain what role you will play in the treatment plan. Specialist wish? As Dr. Burke told you, I'm going to be assisting him in getting your history and physical and evaluating what your condition is now and what your needs are going to be for treatment. So that's why he made an appointment for you to come in and see me this morning. What I'd like to start out with is just having you tell me something about what brought you to see Dr. Burke in the first place. Well, I believe the first of the week I was at the gym. Remember, the patient is the focus of attention. The nurses' questions should reflect the patient's comments in order to verify or clarify information. I was losing a lot of weight and I had lost a lot of weight in a short period of time. Also, I was urinating very frequently. So were these two things the weight loss and the frequent urination and the suggested that you ought to come to the doctor? Yes, ma'am. Okay, fine. I want to talk a little bit more about each of these particular complaints. First of all, the weight loss. What was your total weight loss, recent weight loss? I think during that period of time, about 15, 16 pounds. In what time period was that? In about a week. Just about a week's time. 15 to 16 pounds. Sometimes direct questions of a what, where and when nature are necessary to assist the patient in reconstructing events. An observation of the patient can suggest other areas for exploration. As far as vision goes, did you have any change in your vision? I know you should wear glasses. Did it change in the last six weeks? Yes, of course, only after I had seen the doctor the first time. What about what you wanted to drink in terms of fluids? Did you notice any difference there? An excessive amount of water and of course, I was making a lot of soda too. What kind of soda were you drinking? Grape flavor. Grape flavor, regularly sweetened. Periodically, throughout the interview, summarize and restate information offered by the patient. Okay, so let me just summarize that. That was about nine weeks ago when you had this flu-like episode. Yes, ma'am. And you don't know that it was associated with your diabetes, but it might have been. Right. Okay, fine. Let me just make a note about that so I don't forget it. Demonstrate a display of interest in what the patient is saying by singling out one of his statements and using it to provide direction to the conversation. Let's go back to this episode that you had in 1966. You said you didn't go to a physician at that time. Right. Over the years, have you ever gone to the physician for any problems with your blood pressure? Yes, ma'am. Shortly after this particular incident, my family doctor told me I had high blood pressure. Encourage the patient with verbal responses such as, uh-huh, and non-verbal responses such as a knot of the head or facial expression. Some tranquilizers and that sort of thing, but not very much. Not anything special for the blood pressure itself, an actual blood pressure medicine? No, probably not. Okay, did you go on any type of a special diet at that time with your blood pressure? Yes, and I'm going to tell you, the special diets for me are murderous, but I was on a diet, I tried hard. To extend the content, guide the patient into areas other than the immediate situation, such as family background, personal tastes, cultural patterns, and lifestyle. Can you think of anything else that might be important for me? No, not just offhand. Not with me. I've never really had any illness. Okay, you say not with you, with someone else in your family? I've got a sister, uh, who is diabetic. What about high blood pressure? Does anybody in your family have high blood pressure? Uh, well, my father died from a stroke here, high blood pressure and a stroke. My mother, uh, just recently had a stroke, and she has high blood pressure. Now Dr. Burke has indicated that you're going to need to take insulin. And so what I need to find out from you now is something about a typical day, or your lifestyle, so that we can identify what it is you need to know and concern ourselves with what type of diet teaching you're going to require. Well, this is difficult. Maybe I should tell you about my week first, and then we can go to the next. Okay, that's fine, however. I work on Wednesdays, Fridays, Saturday, and Sunday. I'm off on Monday, Tuesday, and Thursday. Uh, my duty day starts at 12 each day. It starts at 12. On Wednesdays, it ends at 9 at night. On Fridays, it ends at 11. On Saturday, it ends at 12. On Sundays again, it ends at 9. Uh-huh, so it's different, but it starts at 12 each of your work days. Right. That's something I think I should tell you. My fiance is Oriental, and hopefully we should be married before the end of the year. Then I'm sure the situation will change. You have more regular eating patterns with her cooking for you. Okay, what about the type of food? Is she an American born Oriental and cook American style or Oriental? She is Oriental, and she cooks Oriental style, and what happens is that I find myself really becoming Oriental, because I love the food, all of it, and personally I prefer it. Your own knowledge of the patient will play a significant part in helping him to better understand how the plan of care will affect his life and health. It's no problem to figure out how to use Oriental foods in a diabetic diet. It's just that we need to know what it is you're going to be eating. Now, I met at a teen club, a club for teenagers. That's difficult in the sense that you're always doing nice things for little kids, but they're always offering you candy and coke and this sort of thing, and of course you can't accept it if you did. We'd be bigger than the world. Do you get tempted to accept it, which you like to be able to? Oh, yes. Do you have somewhat of a sweet tooth? Well, sort of. I like peanut brittle. In fact, I'm crazy about peanut brittle. Depending on the basic diagnosis of the patient, different aspects of his lifestyle will take on more importance. With this diabetic patient, eating, sleeping, and work patterns are critical in determining the insulin and diet schedule. Okay, on these days when you go to work at 12 o'clock, what time would you normally be getting up in the morning? Late sleeper, early rise or what? Well, generally I get up at 11. You say now that you get up at 11 o'clock before you go to work. Do you eat breakfast before you go to work? No, ma'am. Just coffee. Just coffee. When do you normally eat your first meal of the day? Usually around 4. What would you have at 4 p.m.? What would be typically something that you would eat at that time? Really, sometimes breakfast food, eggs and that sort of thing. Depending on what they've got available at the mess hall where I sometimes eat. And then sometimes it just don't eat. As the nurse listens to the patient, she begins to identify those areas in which the plan can be adapted to the patient schedule. And when the patient schedule will have to be adapted to the plan. Although it will be possible for this patient to take his insulin after his normal waking hour, a change in his eating pattern will be necessary so that it is compatible with his diabetic diet. Do you know anything about diabetes from previous experience? Have you had any opportunity to learn anything? Nothing. I do know that from hearsay about the inconvenience of people taking insulin and this sort of thing, I know that that's going to be a problem. Frankly, it brings up an awful lot of questions for me. That's one of the reasons why I wanted to get a lot of this information, because what I'm going to have to do is there are a lot of things that we'll have to explain or explore and see possible ways and try to suggest some ways and offer them to you and see what best suits you. And we'll give you some suggestions on how to handle this. What others you've said meant several questions? Everything I can gather, that's what's required now, that I now live routinely. And I've never done that so. Do you think if we configure some ways to get the medical treatment in with your life, you'll be able to maybe see how you can get your life a little bit in with the medical treatment? How do you feel about that? Oh, well, I want you to understand that I definitely intend to live. I want to live and I'll make the change. It's just that it's certainly not going to be easy for me. I want to know something about your exercise pattern. Now you say you're involved in management of the teen club. Do you get involved with the exercise in relation to your job? As far as my work is concerned and actual physical exercise, it's all limited to the type thing that musicians do. I'm a musician basically. And I play music, I play hard. I sweat a lot, but that's just about all I do get. I think that's pretty much what I need to get from you now. And what I would like to do is to have you step over to the examination area. And I have an examining row back there and we'll do the physical examination while you're here today. A complete physical examination provides objective data, which when integrated with information from the health history, gives a three-dimensional view of the patient. Special attention is given to parts of the physical exam, which correlate to possible problem areas elicited from the patient during the interview. After the physical examination, the nurse discusses the future direction of the nurse patient relationship. Definitive plans are established for the next meeting. And an explanation is given to the patient about what his role will be in the interim. My plan to do now is take all the information that I found from the history, the physical examination, some of the lab studies have already been done, and some more that I'm going to ask you to have done now. And I'll get together with Dr. Burke and find out exactly how much insulin he wants you to start on. And from all this information, I'll be able to determine what all it is you'll need to learn or need to decide on with me in terms of you're taking care of yourself and once you get started on the insulin. Dr. Burke is anxious for you to get on your therapy, so when can you come back? When are you free? Any time this week. Any time? Can you come early in the morning? Yes, ma'am. Okay, how about starting tomorrow morning? That'll be fine. Okay, I think I'll be able, I won't have any of the lab results back, but I'll be able to have gone over this and have seen Dr. Burke before tomorrow morning. So why don't we set it for tomorrow morning, 8.30? 8.30 is fine. 8.30, okay. When the nurse completes the data gathering part of the assessment process, the next step, analysis begins. It is from this analysis that these specific needs of the patient begin to emerge. For specialist wish, a plan of care that takes into consideration his sleeping patterns, his erratic eating habits, his oriental fiance, and his strong family history of hypertension will have a higher potential for compliance and success than one that is based on a theoretical set of needs for a theoretical or modeled diabetic patient. The nurse discusses her assessment of each patient with the attending physician. And what I've found so far is essentially what you had on history An individual receiving care as an outpatient may require as extensive a health care plan as one admitted to the hospital. Both the physician and nurse contribute to the plan. The physician prescribes the medical regimen, but it is often the nurse who will take the medical orders and incorporate them into a plan compatible with the patient's lifestyle and provide a program teaching him to care for himself. My approach to this patient would be to start them out on 50 units of MPH insulin. You can do this tomorrow morning. Instruct them as... Order's form is that it. No, I think that's about it. Okay, let me just make sure I get them all because we went over several things. Right. It was the 50 units of MPH to start with and the blood sugar at 4 p.m. And then in the morning, the protein electrophoresis and then the patient teaching, all of which you mentioned would be in our normal sequence since he's a brand new diabetic. Okay, good. Then I'll see him tomorrow morning when he comes in and I'll let you know what happens. I think this will be a good plan. Okay, fine. Thanks for coming by. You're welcome. Assessment is an ongoing process and must continue as the patient progresses or as his health status changes. When a patient who is being cared for as an outpatient must be admitted to the hospital for some reason, the ward nursing staff becomes involved in the assessment process. The original and continuing assessments done in the outpatient setting are helpful to the ward nurse in establishing a basis for comparison. She will want to talk with the patient in order to identify how his needs may have changed because of the new situation. Specialist Wish, now that I've discussed your surgery with you and what you can expect in relationship to it, I'd like to have you give me some information about your diabetes so that we can plan nursing care based upon your pattern of care as closely as possible. Yes, ma'am. What time do you usually give your insulin? In the mornings. When you say in the mornings, how early or late? When I would get up as soon as I get up. Do you get up at the same time every day? No. As a rule, I get up at around 11 o'clock. As far as checking your urine... Although the ward nurse's interview may seem to be repeating information previously acquired, you will note that the emphasis is on the present status of the patient's self-care. This will enable the nurse to plan care in the period of hospitalization that will be least disruptive of the patient's normal patterns. You know that you work late in the evening and that generally you get up about 11 o'clock in the morning. Yes, ma'am. Is that correct? So that means that your first meal is at about 12 noon. Yes, it's very light though. A light. I have to admit that at first I was eating a regular breakfast meal. And of course now it's gotten even lighter than that. Lighter. At any time usually do you have a snack during the day? Well, it's not scheduled. What happens is that from time to time I'll have maybe some fruit, things of that nature. That's all. When you have such a snack, is it usually just once during the day or is it several times during the day? Generally it's just once. When you have this snack, is it a period of time where your insulin is acting at its peak or what I mean is there is a low blood sugar? Do you know what I'm talking about here? No, I don't. What about the large meal, the 4 p.m. meal? Well, that varies. Again, depending on where I am, it's so hard to tell you what I actually eat because it changes so much. Well, I think possibly there's some areas here that we will be able to discuss later in relationship to testing your urine and looking at your diet and checking to make certain that you're using the right techniques and giving yourself your insulin. I also think possibly, as I've indicated before, going over some of the signs and symptoms that you could have if there is a low blood sugar or a high blood sugar. Yes, ma'am. When more than one nurse has been involved in the assessment of a patient, it is important that they share their findings so that a fuller understanding of the patient is obtained. Since we're going to have specialist's wish following sharp period of time, I thought we could go over the areas that we've identified for reinforcement for teaching so that you could carry on with him in the clinic. Yeah, but it'll be fine because I have been seeing him between when he first became diabetic in October. I was seeing him about once a week to just make sure he had all the basics. And since that time, I've been seeing him about once a month for reinforcement. There are some areas that require constant reinforcement. Have you had a chance to talk with him? Well, I've had one interview with him in order to assess just the initial beginning related to his diabetes, and this took place right after the orientation to his pre- and post-op care for his early repair. What did you find? He doesn't really understand what I mean by hypo and hyperglycemia. Yes, I'm not surprised. I remember the symptoms on many, many occasions, but you know, since he's been diabetic, it's been almost eight months. He has never experienced yet one episode of hyperglycemia. In fact, if he should have one... Continuity of care is improved through collaboration between the nurses who are planning for different segments of the patient's care. The other large area that I think we'll have to work with is his diet. When I got his dietary pattern from our discussion, it seems like, of course, his meal times are totally different, which I'm certain you're very aware of, from the normal pattern of early in the morning, mid-noon, and then after work, which might only be right from 9-12. After surgery when he goes back on his normal NPH insulin dosage, then I think we'll have to look at his time schedule for meals. Now, it will be impossible with his meals at 11 and 4 in midnight to really provide this kind of schedule for his care during the entire hospital stay. However, what I thought we could do is within the last day or two of his hospitalization, I could make special arrangements with the kitchen so that we could give him his first meal at 11 in the morning with a 4.30 or 5 o'clock meal time, which is a usual meal at that time, and then having a cold snap prepared for late evening so that when he is discharged, he can get back more easily into his regular pattern of eating. That would be very good. I think that pretty much covers the areas that my nurses and I have identified as far as specialist's wish is concerned. Okay, I have one more thing I would like to ask of you. While he is in the hospital, he has had a borderline blood pressure elevation for, we don't know exactly how long, at least back to when I first started seeing him last August, and it's always ranged right around 140 over 90, not enough to require any kind of therapy, Dr. Berksfeld, but enough to bear watching. This will be the first time we've had an opportunity to really observe his blood pressure pattern over a 24-hour period, and I know normally after herniography you wouldn't be taking routine blood pressure as much past the immediate post-op phase, but I would appreciate it if you would keep him on blood pressures along with your routine vital signs schedule. I can't think of anything else from my viewpoint. I will, you know, of course, leave his record up here and he's going to surgery tomorrow, is that correct? That's right. And I'll be up to see him then sometime in the post-op phase before he's ready for discharge. When assessing the patient's needs, it is important that a broad view of the patient be undertaken. This involves exploration into various psychological, physiologic, sociologic, cultural, and economic factors. Good assessment leads to individualized healthcare planning and, in turn, to improved acceptance of illness by the patient, a higher degree of compliance with his treatment plan, and a quicker return to as normal a lifestyle as possible.