Nursing Management: Initial Comprehensive Assessment

Nursing Management
Assessment: Initial comprehensive assessment is completed on patient to establish the baseline and after that the assessment of the patient is continuous and systematic throughout patient care. Assessment is essential because it forms the information on patient database and helps the care team to provide evidenced based nursing care. Upon assessment of the heart transplant patient the subjective and objective data are collected and they include: Health history, physical examination, and social history. Health history should include information about complaints of respiratory distress such as shortness of breath, dyspnea with exertion, decreasing activity tolerance, weight gain, and presence of cough. Appetite should be discussed to assess if patient has anorexia or nausea. Information about other diagnoses such as hypertension and diabetes, as well as reviewing current medications, diet and activities should be discussed. Physical examination should include a complete set of vital signs and an inspection of the mucous membranes for signs of dehydration. Observe the patient’s general appearance, ability to ambulate, and the ease or
Assess gross range of motion of all extremities. Note the percentage of shoulder flexion and abduction. It should be looked at unilaterally per sternal precautions. Note any limitations in spine mobility related to abnormal postures. Strength of the patient’s extremities should be assessed. Assess gross strength and consider the potential development muscle weaknesses that may have occurred due to bed rest and/or the effects of anti-rejection steroids. Muscle weakness may cause patient difficulty with sit to stand transfers. Assess patient’s ability to perform bed mobility, transfers, and ambulation on all surfaces to include level surfaces, upstairs, downstairs and uneven surfaces. This is important to prevent falls, sprains, strains and other