What You Should Put In Your Nursing Assessment Documentation (part 2)

Photo courtesy of Christiana Care (Flickr.com)

In part 1 of our discussion, we have pointed out that limiting your nursing assessment with the sign or symptom would result in a poorly planned and executed care plan. Aside from the sign (1), the nurse should note the (2) onset, (3) location, (4) duration and (5) character of the sign or symptom. Let’s continue, shall we? (Later, we will also have a nursing assessment example that applies what we have discussed here.)

6.       Aggravating factors. Aside from the sign and symptom, the nurse should also look at the possible causes and risk factors that brought about the problem. If the client is experiencing stomach cramps, you could ask about things that usually cause or trigger stomach cramps. “Do you drink coffee?” “How many cups of coffee do you drink in a day?” “Do you frequently eat spicy food?” “What was the last food that you ate?”

Aside from exploring the etiology and risk factors, the nurse should include information that makes the symptoms worse in the nursing assessment documentation. For a person experiencing difficulty of breathing (DOB), you could ask the patient if he had any strenuous activity prior to the onset of DOB. Does he smoke? How many cigarettes per day?

7.       Relieving factors. Likewise, the nurse should also explore about things that lessen or alleviate the symptoms felt by the patient. In our example regarding stomach cramps, we could ask the patient regarding the medications that he takes. Does the medication relieve the symptoms? Other than medications, is there anything else that the patient does that lessens the symptom?

8.       Timing of the sign/symptom. This assessment parameter in the nursing assessment documentation, the nurse takes note of the frequency of the symptom, and which time of day do the symptoms appear. Going back to our client experiencing stomach aches, we could ask: “Is there any particular time of the day that you experience stomach cramps?” “How many times in a day do you feel these stomach cramps?” Moreover, the nurse should also note of the time interval between symptoms.

9.       Severity. This is perhaps one of the most important parameters that should be included in the nursing assessment documentation. Aside from the character of the symptom, patients are also particular with the severity of what they are experiencing. The perfect example to demonstrate the assessment of severity is pain: how painful is it? One great tip in assessing the severity of pain is by using a pain scale. On a scale of 1-10, with 10 being the highest level of pain, have the patient rate the pain using the scale. With children, the nurse can use the Wong-Baker Faces Pain Scale.

In exploring a patient’s sign or symptom, remember this acronym: OLDCARTS (onset, location, duration, character, aggravating factors, relieving factors, timing and severity). Although there are many things to explore about a symptom, this guide is already a good start for you to have substantial nursing assessment documentation. Aside from our discussion, don’t forget to always practice your assessment skills. Know your patient, and learn how to ask assessment questions properly. Moreover, keep in mind that nursing assessment is not just about knowledge and skills; you have to learn how to interact well with your clients to help identify their nursing problem and formulate the appropriate nursing care plan for the problem.

What You Should Put In Your Nursing Assessment Documentation (part 1)

Photo courtesy of Christiana Care (Flickr.com)

Most nurses struggle with what to put on the patient’s chart or with a good working nursing assessment example, especially when it comes to putting assessment data on the nurse’s notes. Nurses often ask themselves where to draw the line between relevant and irrelevant data, and “too much” or “too few” data - and this becomes a source of numerous documentation problems. When the chart lacks substantial data, the nurse finds it difficult to determine a patient’s problem. Consequently the nursing care plan would be inefficient in solving the problem. On the other hand, if the nursing assessment documentation has too much data, it would create confusion for the nurse on how to properly cluster and organize it to come up with a relevant care plan.

With this in mind, it’s time to ask: what should you put in your nursing assessment documentation, to ensure that you would be able to accurately identify a nursing diagnosis and make the necessary plan of care for that diagnosis? While there are numerous ways to make proper documentation, let me share with you a tested framework that can help you achieve accurate and relevant documentation:

1.       Identify the sign or symptom. This is always the first thing to do. Is the client experiencing pain? Fever? Cough? Difficulty walking? A problem with urinating? If you’re going to ask the patient about a symptom, it’s categorized as subjective data, and should be included in the patient’s health history. With subjective data, you should take note of the patient’s verbalizations as he describes it. If you found a sign during a physical exam, you must document the sign with the appropriate term (i.e. ecchymosis, pallor, cyanosis)

2.       Ask about the onset of the sign or symptom. When did it start? Whatever the client states, it would give you an idea of whether the problem is long-term or short-term. It’s not enough to document only “cough” in your nursing assessment documentation. Having knowledge of the onset will also hold a clue to the cause of the problem. A short onset of cough can be caused by a common viral infection, while a cough that started three months ago may be due to chronic obstructive pulmonary disease.

3.       Where’s the symptom located? Is the problem located in a small region of the skin? Does it involve a larger portion, like a limb? Does the symptom occur bilaterally? Do the signs occur on the whole body? Having noted the symptom’s location would hold clues on the characteristics of the disease. Local lesions that progress to systemic lesions over a period of time could tell that the disease is worsening. The location would also tell which part of the body is experiencing a pathological condition. For example, pain felt at the right upper quadrant of the abdomen might be due to a liver or gallbladder disease.

4.       How long has he been experiencing this symptom? Having knowledge of the duration of the problem is equally important; it can determine if the problem is acute or chronic. Acute pain can be attributed to short-term injury or inflammation, while pain that has been occurring for more than 6 months might be a signal for a chronic condition such as cancer.

5.       Let the patient characterize the symptom. Taking note of the character of the symptom on the nursing assessment documentation can significantly improve the way nurses diagnose and treat client responses. A patient who describes an “excruciating” pain on his limbs might be experiencing a fracture. A client who is experiencing a “hacking” cough might be developing lung cancer. A patient who tells that “something kinda gave way” on his operative site might be experiencing wound dehiscence.

Remember that documenting the symptom or sign alone is not enough; you have to know and document the (1) onset, (2) location, (3) duration and (4) character of the sign or symptom. 

Click for part 2 of this discussion.

Nursing Assessment: Why It's Important

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Most nurses see it as a challenging task to make accurate and comprehensive nursing assessment documentation because there are lots of factors that affect the process. A good nursing assessment can be obtained if the nurse has the ability to consider both nurse factors and client factors, and adapt effectively with the situation brought about by these factors.

Most nurses take nursing assessment for granted; even though the topic is constantly being emphasized in lectures. Most nurses are very much preoccupied with medication administration, assisting with medical procedures and carrying out of doctor’s orders, but they fail to realize that the nursing process is the core of their profession, and nursing assessment is the first step. It is necessary to point out that the nursing process involves a step-by-step procedure, thus a poorly conducted assessment will lead to a poorly executed care plan.

Nursing assessment is important, and here’s why:

• It provides basis for formulating nursing diagnoses. Nursing assessment is perhaps the most important step of the process because it will direct you to precisely diagnose a client’s response to illness. Without assessment, the nurse would be unable to determine which aspect of the client’s health needs nursing assistance. It’s also parallel with the medical process, where the physician gathers the necessary data in order to arrive at a medical diagnosis. It’s just like detective work: how can you establish the case if you don’t have evidence to prove it?

• It guides the care plan. The assessment data also helps the nurse in setting the outcome criteria that are needed in the care plan. For example, if the client is experiencing fever, the nurse would accordingly set outcomes related to temperature regulation. 

• It provides baseline for evaluation. Assessment also directs the final step of the nursing process: evaluation. The data that you’ve gathered provides baseline values, and it tells the degree of deviation from the normal values. If the data are accurate and comprehensive, it would be easier for the nurse to set outcome criteria and determine if the client’s condition has improved based on the criteria. 

• It complements other people’s efforts for the patient. Aside from the benefits brought to the nursing process, nursing assessment also helps the other members of the healthcare team; if some piece of data about the client was not uncovered or examined by the other healthcare team members, the assessment data made by the nurse might have the necessary data that would fill it up. That’s the good thing about working with a team; even though each member uses the patient data differently, the data can be used by the whole team.

There are numerous points to consider why nursing assessment is important, but the crucial point is that without accurate and comprehensive assessment, it’s virtually impossible to carry out any nursing care plan.