Palm Beach State College
August 26, 2012
Nursing assessment is one of the main stages of the nursing process. According
to Webster’s dictionary, “nursing assessment is the gathering of information about a
patient’s physical, psychological, sociological, and spiritual status”. As professional
nurse’s, we are responsible to use skills to complete assessments on every patient
that we care for. Collecting this information allows us to prioritize the care and
initiate interventions. How well we assess our patients determines if there is a positive or negative outcome. One positive outcome, that occurred
from utilizing complete assessment skills, happened when I worked in a long term
care facility.
First of all, the frequency of a complete assessment varies in different health care
settings. (Jensen, 2011). Working in a nursing home many of the residents only
require once a month thorough head to toe assessments. However, there is a more
acute area in the facility, and this was where my assessment skills and interventions
led to a positive outcome. Poor Mary Jane (fictitious name), a 75 year old frail
female, had multiple urinary tract infections (UTI), and was put on IV antibiotics.
This was the first day I cared for her, but the fourth day of being on the antibiotics. I
recall assessing the IV site and listening to her lungs and while I was doing this I
noticed her back was broken out in hives! I thought…she was having an adverse
reaction to the medication. Studies show that older people in long-term care
facilities suffer from a higher number of adverse drug reactions. One study
conducted estimated that forty-two percent of adverse drug reactions were
preventable. (Jordan, 2007) After assessing her upper body I then assessed her
lower extremities and noticed smaller hives initiating on her lower
References: Jordan, S. (2007). Adverse drug reactions: reducing the burden of treatment. Nursing Standard, 21(34), 35-41 Rubenstein L., Calkins D., Greenfield D.,et al. (1998) Systemic Biases In Functional Status Assessment Of Elderly Adults: effects of different data sources. Journal of Gerontology. 1998;37:562-569.