Next Assessment Steps and Data Documentation (Nursing)

by Samantha Rhea, MSN, RN

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    00:02 Now, another way that we gather information, is of course, let's look at those next assessment steps.

    00:08 So physical examination gives us so much information, guys.

    00:12 Now, how do we assess? If you remember, there's that inspection, where we palpate or percuss.

    00:18 We listen by auscultation.

    00:21 This is going to collect valuable objective information.

    00:25 Again, guys, I can't stress physical examination enough.

    00:29 If we don't physically or do a head to toe assessment on our patient, we don't have tangible information on our patient's condition.

    00:38 Also, if you don't do a thorough head to toe assessment, or physical examination, there may be important key pieces that we're missing in that assessment phase.

    00:48 It's also important when we're examining or taking care of our patient, look at that verbal versus nonverbal information your patient gives you.

    00:56 Look at their behavior.

    00:58 So this is going to help us gather information.

    01:01 Here's a great example of this.

    01:03 I have my patients do this all the time.

    01:06 I'll go into my patient's room and say, "Hey, Mr. Jones, are you having any pain right now?" And they're like, "No, I'm not having any pain." But then when I watch them, they may be grimacing, they may be really restless, they've just had surgery.

    01:19 When they get up to the bathroom, they're limping, they're really uncomfortable.

    01:23 As you can see, the person's verbal versus their nonverbal behavior didn't match, right? So as a nurse, I need to be cognizant of this and make sure I take that into account as well.

    01:37 Now, this is a little bit more difficult.

    01:39 And this comes a little bit more with experience as a nurse.

    01:43 So taking that diagnostic information, this is going to give us additional supportive information in that plan of care.

    01:52 This also may change our treatment for a patient.

    01:55 What I'm talking about is maybe a critical lab value, for example.

    01:59 Let's say your patient has a really high potassium that's important that we treat, right? Also, this may be something might change with like a chest X-ray, if we have brand new results.

    02:10 This is also important to include all that diagnostic information with your physical assessment, with for the clinical picture of your patient.

    02:20 And then lastly, interpreting and validating that assessment data is really important.

    02:25 So using all of this information, such as your assessment, maybe labs and diagnostics, your patient behavior, this is all going to take, all going to be really important to help drive what our priority problem or maybe our nursing diagnosis.

    02:43 Also important that we cluster this data and look for patterns or trends to compare them with normal or abnormal standards.

    02:53 Now let's talk about assessment data and data documentation.

    02:58 Guys, this is such an important piece because as you know, if it wasn't documented, it wasn't done.

    03:04 The reason why we talk about this is if I'm a new nurse coming on this shift, and there's other information that wasn't documented previously, I don't know if this is the trend of the patient.

    03:16 Is this normal? Is this abnormal? That definitely affects the continuity of care.

    03:22 Also, don't forget the client record is a legal document.

    03:27 So it's really critical that we use accurate and approved terminology.

    03:31 Here's what I mean by this.

    03:33 If we're using just random terminology that we make up ourselves, you can imagine by if someone reviews that probably isn't the most credible source when you review this documentation.

    03:46 If it's not accurate, or if it's just random made up terminology that's documented in the patient's record.

    03:53 And this must be completed within a timely manner.

    03:56 So I really encourage you that as soon as you do something, if you can, document it.

    04:02 Reason being, is many times we'll forget details that are really important to the patient's record, if we don't document within a timely manner.

    About the Lecture

    The lecture Next Assessment Steps and Data Documentation (Nursing) by Samantha Rhea, MSN, RN is from the course Nursing Process – Assessment, Diagnosis, Planning, Interventions, and Evaluation.

    Included Quiz Questions

    1. “Now that I’ve finished with my questions, I’d like to move on to the physical assessment, if that’s okay?"
    2. “You mentioned that you weren’t in any pain, but I noticed you’re favoring your left arm. Is your right arm bothering you?”
    3. “When we’re done here, I’m going to see if your lab results have come back yet.”
    4. “You’ve answered my questions, so that's the end of the assessment. I’ll let you get some rest.”
    1. Head to toe assessment was completed at start of shift eight hours ago, no abnormal findings
    2. H2TA completed
    3. The client is a 50-year-old male presenting with arm pain, writer is unable to recall which arm
    4. The client is a 70-year-old woman presenting with a four-day history of right upper quadrant pain

    Author of lecture Next Assessment Steps and Data Documentation (Nursing)

     Samantha Rhea, MSN, RN

    Samantha Rhea, MSN, RN

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