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The ABCs of Nursing Assessment: A Comprehensive Guide
Author: Dr. Eleanor Vance, RN, PhD, FAAN
Dr. Eleanor Vance is a registered nurse with a PhD in nursing science and a Fellow of the American Academy of Nursing. She has over 20 years of experience in critical care nursing and has published extensively on nursing assessment methodologies. Her expertise lies in developing and implementing evidence-based assessment strategies for diverse patient populations.
Publisher: Elsevier Health Sciences
Elsevier Health Sciences is a leading global publisher of medical and healthcare information, known for its high-quality, peer-reviewed journals and textbooks. Their expertise spans various areas of healthcare, including nursing education and practice.
Editor: Dr. Margaret Chen, RN, MSN, CEN
Dr. Margaret Chen is a registered nurse with a Master of Science in Nursing and a Certified Emergency Nurse. She has extensive experience in editing medical publications and ensuring accuracy and clarity in healthcare communication.
Keywords: abc of nursing assessment, nursing assessment, patient assessment, clinical assessment, ABCs of patient assessment, systematic assessment, nursing process, assessment techniques, physical assessment, subjective data, objective data, health assessment, holistic assessment.
Introduction: Mastering the ABCs of Nursing Assessment
The "ABCs of nursing assessment" – Airway, Breathing, and Circulation – represent the foundational elements of a rapid, focused assessment prioritizing immediate life threats. While seemingly simple, mastering the ABCs and understanding their integration into a comprehensive nursing assessment is crucial for providing safe and effective patient care. This article delves into the methodologies and approaches used in the abc of nursing assessment, expanding beyond the initial ABCs to encompass a holistic view of the patient's health status.
1. The Initial ABCs: Airway, Breathing, and Circulation
The initial assessment, often performed in emergency situations, centers on the ABCs. A compromised airway necessitates immediate intervention, followed by assessing breathing effectiveness (rate, depth, effort) and circulatory status (pulse, blood pressure, skin perfusion). This prioritization ensures stabilization before proceeding to a more detailed assessment. The abc of nursing assessment in this context is life-saving and requires rapid, skilled decision-making.
Methodologies: Observation, palpation, auscultation, and measurement of vital signs are key methodologies used during this initial assessment. For example, observing respiratory effort for signs of distress, palpating for a radial pulse, and auscultating lung sounds to identify any abnormalities are vital steps.
2. Expanding the ABCs: Adding Disability and Exposure (ABCDE)
The ABCs are often expanded to include Disability (neurological status – level of consciousness, pupillary response) and Exposure (a complete head-to-toe physical examination, ensuring proper temperature control). This ABCDE approach provides a more comprehensive initial assessment, enabling identification of potential secondary problems beyond immediate life threats. The abc of nursing assessment, therefore, moves beyond simple observation to encompass a more systematic approach.
Methodologies: The Glasgow Coma Scale (GCS) is commonly used to assess disability, while a systematic head-to-toe examination utilizing inspection, palpation, percussion, and auscultation forms the basis for exposure assessment. Accurate documentation of findings is crucial for effective communication and ongoing care.
3. Subjective Data Collection: The Patient's Story
The abc of nursing assessment doesn't end with objective findings. Gathering subjective data, the patient's own perspective on their health, is equally critical. This involves active listening, empathetic communication, and asking open-ended questions to understand the patient's symptoms, medical history, and concerns. This information, combined with objective findings, provides a complete picture of the patient's health status.
Methodologies: Employing effective communication techniques such as therapeutic communication and using validated assessment tools (e.g., pain scales) are essential for accurately collecting subjective data. Documenting the patient's own words is crucial to maintain accuracy and context.
4. Objective Data Collection: The Physical Examination
A thorough physical examination forms the core of objective data collection in the abc of nursing assessment. This involves systematically assessing all body systems, utilizing techniques such as inspection, palpation, percussion, and auscultation. This process requires a keen observational skill and a systematic approach to ensure no area is overlooked.
Methodologies: Following a standardized head-to-toe assessment format, utilizing appropriate equipment (e.g., stethoscope, ophthalmoscope), and accurately documenting findings are key methodologies. Specialized assessment tools, such as neurologic examinations or cardiac assessments, may be used depending on the patient's condition.
5. Integrating Subjective and Objective Data: A Holistic Approach
The true power of the abc of nursing assessment lies in integrating subjective and objective data. This holistic approach allows for a comprehensive understanding of the patient's health status, facilitating accurate diagnosis and development of an individualized care plan. For example, a patient reporting chest pain (subjective) coupled with abnormal lung sounds (objective) points toward a potential respiratory or cardiac issue.
Methodologies: Critical thinking and clinical reasoning are essential to effectively synthesize subjective and objective data. This process involves identifying patterns, drawing inferences, and ruling out competing diagnoses. This integrated approach forms the basis of effective decision-making in the abc of nursing assessment.
6. Documentation and Communication: The Foundation of Safe Care
Accurate and timely documentation of the abc of nursing assessment is crucial for continuity of care and effective communication among healthcare providers. This involves clear and concise recording of subjective and objective findings, using standardized terminology and following institutional guidelines. Clear communication ensures that the findings are shared effectively with other members of the healthcare team.
Methodologies: Utilizing electronic health records (EHRs), following established documentation protocols, and ensuring clear and concise writing are vital methodologies for effective documentation.
7. Continuous Assessment: The Dynamic Nature of Patient Care
The abc of nursing assessment isn't a one-time event; it's an ongoing process. Patients' conditions can change rapidly, requiring continuous monitoring and reassessment. Regular monitoring of vital signs, observation for changes in symptoms, and reassessment of the patient's response to interventions are essential for providing safe and effective care. The abc of nursing assessment, therefore, is a dynamic process that adapts to the changing needs of the patient.
Methodologies: Regular rounds, frequent vital sign monitoring, and prompt response to changes in the patient's condition are key methodologies for continuous assessment. This requires vigilance, clinical judgment, and effective communication among healthcare providers.
Conclusion
Mastering the abc of nursing assessment is fundamental to providing safe and effective patient care. It requires a systematic approach, combining a rapid initial assessment focusing on life-threatening conditions with a thorough and holistic evaluation of the patient's overall health status. By integrating subjective and objective data, utilizing appropriate methodologies, and ensuring clear communication and documentation, nurses can deliver high-quality, individualized care. The ongoing nature of the abc of nursing assessment underscores the importance of continuous monitoring and adaptation to the dynamic needs of the patient.
FAQs
1. What is the difference between subjective and objective data in nursing assessment? Subjective data is information provided by the patient (e.g., pain level, feelings), while objective data is information obtained through direct observation or measurement (e.g., vital signs, physical exam findings).
2. What are the key components of a complete physical assessment? A complete physical assessment includes assessment of vital signs, general appearance, head-to-toe examination of all body systems (neurological, respiratory, cardiovascular, gastrointestinal, etc.), and any other assessments specific to the patient's condition.
3. How often should a patient's vital signs be monitored? The frequency of vital sign monitoring depends on the patient's condition. Critical patients may require continuous monitoring, while stable patients may only need monitoring every 4-8 hours.
4. What are some common assessment tools used in nursing? Common assessment tools include pain scales, Glasgow Coma Scale (GCS), Braden Scale for predicting pressure ulcers, and various specialized scales depending on the body system being assessed.
5. What is the role of critical thinking in nursing assessment? Critical thinking allows nurses to analyze data, identify patterns, make inferences, and arrive at appropriate conclusions and nursing diagnoses.
6. How can nurses improve their assessment skills? Nurses can improve their assessment skills through ongoing education, practice, mentoring, and seeking feedback from experienced nurses.
7. What is the importance of accurate documentation in nursing assessment? Accurate documentation ensures continuity of care, facilitates communication among healthcare providers, and provides a legal record of the patient's care.
8. What is the significance of the ABCDE approach? The ABCDE approach (Airway, Breathing, Circulation, Disability, Exposure) provides a structured and prioritized approach to assessing patients in emergency situations.
9. How does the abc of nursing assessment contribute to patient safety? The abc of nursing assessment helps identify and address life-threatening issues promptly, reducing the risk of adverse events and improving patient outcomes.
Related Articles
1. Prioritizing Patient Needs Using the ABCs: This article focuses on applying the ABCs in various clinical scenarios, prioritizing interventions based on immediate threats to life.
2. Advanced Techniques in Physical Assessment: This article explores advanced techniques for specific body systems, including detailed cardiac and neurological assessments.
3. The Role of Subjective Data in Differential Diagnosis: This article discusses the critical role of patient-reported symptoms in arriving at accurate diagnoses.
4. Effective Communication in Nursing Assessment: This article focuses on communication strategies to gather comprehensive subjective data from diverse patient populations.
5. Using Technology to Enhance Nursing Assessment: This article explores the use of electronic health records and other technologies in improving the efficiency and accuracy of nursing assessments.
6. Legal and Ethical Considerations in Nursing Assessment: This article examines the legal and ethical responsibilities of nurses during the assessment process.
7. Cultural Competence in Nursing Assessment: This article emphasizes the importance of considering cultural factors when assessing patients from diverse backgrounds.
8. The ABCs of Pediatric Nursing Assessment: This article focuses on the specific considerations for assessing children and infants.
9. The ABCs of Geriatric Nursing Assessment: This article addresses the unique challenges and considerations for assessing older adult patients.
| abc of nursing assessment: Patient Assessment and Care Planning in Nursing Lioba Howatson-Jones, Mooi Standing, Susan Roberts, 2012-06-22 Nurses of the future need to accurately assess people of all ages, with varying mental and physical problems, across different settings and within a changing healthcare environment. This book introduces nursing students and novice practitioners to different stages of the assessment process. It covers a range of issues including the nurse's role in assessment, how to make sense of patient information, using assessment tools, nursing diagnosis, care planning principles and nursing models, ethical dilemmas in assessment and decision-making in delivering nursing care. The book encourages the development of a person-centered, critical approach rather than an overreliance on assessment tools. |
| abc of nursing assessment: Oxford Handbook of Critical Care Nursing Fiona Creed, Jessica Hargreaves, 2016 A practical, concise, easily accessible and evidence-based guide for all levels of nursing staff working in critical care environments. |
| abc of nursing assessment: Health Assessment in Nursing Peter Lewis, 2011 |
| abc of nursing assessment: Assessment and Decision Making in Mental Health Nursing Sandra Walker, Diane Carpenter, Yvonne Middlewick, 2013-09-25 Assessment is an essential part of mental-health nursing and as such a core learning requirement for pre-registration nursing students. Getting assessment right is essential for the nursing student in order for them to become an effective practitioner. Many books on assessment are very theoretical. This is a practical, hands-on guide to the assessment process, underpinned by the latest evidence. The book explains the core principles through running case studies, so that readers can see how each decision they make impacts on the person in their care. Key features: Assessment principles are applied across a variety of modern nursing settings that you may find yourself working in as a registered nurse Each chapter is linked to the relevant NMC standards and Essential Skills Clusters so you know you are meeting the professional requirements Activities throughout help you to think critically and develop essential graduate skills. |
| abc of nursing assessment: Health Assessment Anna T. Crouch, Clency Meurier, 2015-08-12 Health assessment is central to effective planning, implementation and evaluation of nursing care. All nurses are accountable for the care they provide and need to be able to accurately determine patient needs in order to plan and deliver evidence-based care. Vital notes for nurses: Health assessment provides students with the knowledge required to consider the many different factors which can influence patient’s health, comfort, well-being and recovery and to confidently assess patient needs. Vital notes for nurses: Health assessment explores concepts of holism, health and illness, factors to consider when assessing patients, communication skills needed for assessment, and all aspects of holistic assessment including physical, psychological, social, cultural and spiritual factors and nutritional needs. * Provides a concise, accessible introduction to health assessment * Includes physical, psychological, social, cultural and spiritual health assessment * Explores essential concepts in assessment and care planning * Within the Vital Notes for Nurses series * Adopts a holistic approach |
| abc of nursing assessment: Nursing Assessment Jon Haws, 2015-03-26 ACE Nursing Assessment:: On the go Head-to-Toe Health Assessment. The physical assessment can bring butterflies to any nursing student . . . it did for me! It's hard to remember the order, the technique, the process, and all the abnormalities. In Nursing Assessment you'll learn: 1. How to have confidence when giving a physical assessment to your patient. 2. How to quickly give a physical assessment 3. How to spot abnormal findings on your patients. 4. Understand basic anatomy with a brief anatomy lesson at the beginning of each section 5. Understand assessment techniques for head-to-toe assessment. The health assessment book for nursing students helps relieve that pressure and anxiety by providing a NO FLUFF, easy to read, full of pictures physical assessment that you can easily learn. You + NRSNG = Confidence. Listen, I've been there . . . nursing school is hard, sometimes professors are hard. I felt like I was drinking from a fire hose. On top of that they told me they were going to film me while I completed a physical assessment . . .what! I searched all over the internet looking for a concise resource that condensed the health assessment in an easy to learn format. This book does all that and more! The book is packed full of pictures and resources. Included in This Book -Basic Anatomy -Assessment Technique by Body System -Abnormal Findings -Resources (videos, charts, assessment sheets, clinical organizer) Its time you take control of your nursing studies . . . NRSNG is the leader in helping nursing students ACE the NCLEX and pass nursing school. Scroll up to buy! The book includes ONLY adult physical assessment techniques. |
| abc of nursing assessment: Fragility Fracture Nursing Karen Hertz, Julie Santy-Tomlinson, 2018-06-15 This open access book aims to provide a comprehensive but practical overview of the knowledge required for the assessment and management of the older adult with or at risk of fragility fracture. It considers this from the perspectives of all of the settings in which this group of patients receive nursing care. Globally, a fragility fracture is estimated to occur every 3 seconds. This amounts to 25 000 fractures per day or 9 million per year. The financial costs are reported to be: 32 billion EUR per year in Europe and 20 billon USD in the United States. As the population of China ages, the cost of hip fracture care there is likely to reach 1.25 billion USD by 2020 and 265 billion by 2050 (International Osteoporosis Foundation 2016). Consequently, the need for nursing for patients with fragility fracture across the world is immense. Fragility fracture is one of the foremost challenges for health care providers, and the impact of each one of those expected 9 million hip fractures is significant pain, disability, reduced quality of life, loss of independence and decreased life expectancy. There is a need for coordinated, multi-disciplinary models of care for secondary fracture prevention based on the increasing evidence that such models make a difference. There is also a need to promote and facilitate high quality, evidence-based effective care to those who suffer a fragility fracture with a focus on the best outcomes for recovery, rehabilitation and secondary prevention of further fracture. The care community has to understand better the experience of fragility fracture from the perspective of the patient so that direct improvements in care can be based on the perspectives of the users. This book supports these needs by providing a comprehensive approach to nursing practice in fragility fracture care. |
| abc of nursing assessment: Acute Stroke Nursing Jane Williams, Lin Perry, Caroline Watkins, 2013-05-07 Stroke is a medical emergency that requires immediate medical attention. With active and efficient nursing management in the initial hours after stroke onset and throughout subsequent care, effective recovery and rehabilitation is increased. Acute Stroke Nursing provides an evidence-based, practical text facilitating the provision of optimal stroke care during the primary prevention, acute and continuing care phases. This timely and comprehensive text is structured to follow the acute stroke pathway experienced by patients. It explores the causes, symptoms and effects of stroke, and provides guidance on issues such as nutrition, continence, positioning, mobility and carer support. The text also considers rehabilitation, discharge planning, palliative care and the role of the nurse within the multi-professional team. Acute Stroke Nursing is the definitive reference on acute stroke for all nurses and healthcare professionals wishing to extend their knowledge of stroke nursing. Evidence-based and practical in style, with case studies and practice examples throughout Edited and authored by recognised stroke nursing experts, clinicians and leaders in the field of nursing practice, research and education The first text to explore stroke management from UK and international perspectives, and with a nursing focus |
| abc of nursing assessment: Nursing Health Assessment Sharon Jensen, 2014-10 Forlagets beskrivelse: Nursing Health Assessment: A Best Practice Approach reflects a progressive and modern view of nursing practice, featuring innovative elements that facilitate understanding of how best to obtain accurate data from patients. It includes thorough and comprehensive examinations for each specific topic, and also presents strategies for adapting questions and techniques when communication is challenging, the patient's responses are unexpected, or the patient's condition changes over time. Unique features assist with application and analysis, enhancing critical thinking skills and better preparing readers for practice. Each chapter includes a case study that requires critical thinking and diagnostic reasoning to analyze data, document, plan care, and communicate findings. Additional features, ancillary material, and media related to the book build on the in-text cases to reinforce correct elements of subjective and objective data collection and variations necessary for different problems, age groups, and cultures. |
| abc of nursing assessment: Understanding Supervision and Assessment in Nursing Áine Feeney, Su Everett, 2019-11-25 A practical guide for registered nurses in all fields, who are planning to undertake one of the new supervisor or assessor roles outlined in the latest NMC standards. The book helps nurses prepare for the role of practice supervisor, practice assessor or academic assessor, by outlining what is expected in each of the roles, in accordance with the 2018 NMC standards, and explaining which competencies are needed to ensure success in the new supervisory and academic positions. These competencies include: · Understanding how students learn · Understanding how to empower nurses and why this is important · Learning to utilise student feedback to enhance your own development · Identifying the importance of including the participation of service users in nursing governance and quality · Ensuring compliance with all legal, regulatory, professional and educational requirements. It will also be useful for experienced NMC mentors and practitioners looking to update their skills for the new NMC Educational Framework. |
| abc of nursing assessment: Nursing Interventions Classification (NIC) Gloria M. Bulechek, PhD, RN, FAAN, Howard K. Butcher, Joanne M. McCloskey Dochterman, PhD, RN, FAAN, Cheryl Wagner, 2012-11-01 Covering the full range of nursing interventions, Nursing Interventions Classification (NIC), 6th Edition provides a research-based clinical tool to help in selecting appropriate interventions. It standardizes and defines the knowledge base for nursing practice while effectively communicating the nature of nursing. More than 550 nursing interventions are provided - including 23 NEW labels. As the only comprehensive taxonomy of nursing-sensitive interventions available, this book is ideal for practicing nurses, nursing students, nursing administrators, and faculty seeking to enhance nursing curricula and improve nursing care. More than 550 research-based nursing intervention labels with nearly 13,000 specific activities Definition, list of activities, publication facts line, and background readings provided for each intervention. NIC Interventions Linked to 2012-2014 NANDA-I Diagnoses promotes clinical decision-making. New! Two-color design provides easy readability. 554 research-based nursing intervention labels with nearly 13,000 specific activities. NEW! 23 additional interventions include: Central Venous Access Device Management, Commendation, Healing Touch, Dementia Management: Wandering, Life Skills Enhancement, Diet Staging: Weight Loss Surgery, Stem Cell Infusion and many more. NEW! 133 revised interventions are provided for 49 specialties, including five new specialty core interventions. NEW! Updated list of estimated time and educational level has been expanded to cover every intervention included in the text. |
| abc of nursing assessment: Health Assessment for Nursing Practice Susan Fickertt Wilson, Jean Giddens, 2009 'An Introduction to Television Studies' is a comprehensive introduction to the field. It provides resources for thinking about key aspects and introduces institutional, textual, cultural, economic, production and audience-centred ways of looking at television. |
| abc of nursing assessment: Rapid Assessment of the Acutely Ill Patient Sheila Adam, Mandy Odell, Jo Welch, 2010-01-11 Rapid Assessment of the Acutely Ill Patient sets out the principles and practices needed for early recognition and assessment of patients either at risk of or showing signs of acute deterioration, or those recently relocated from higher levels of care. The focus is on patient assessment, interpretation and evaluation of data, immediate management of significant problems, ongoing and further assessments in order to improve clinical outcomes. Rapid Assessment of the Acutely Ill Patient provides a framework for a systematic initial patient assessment and explores principles of effective assessment. Body systems are considered in order of life-threatening priority following the ABCDE approach, dealing with the assessment and management of airway, breathing, circulation, disability - and everything else; covering topics such as visual, palpatory and auscultatory assessment, use of additional documented information (charts, notes etc), and interpreting diagnostic investigations. Methods to ensure effective communication and team-working are also discussed. Key features Part of the Essential Clinical Skills for Nurses series Aimed at nurses working in wards and specialist departments Explores the assessment skills required for a rapid response to a patient at risk of becoming acutely unwell Enables students and practitioners to develop practical and interpretative skills Provides a framework for assessment and principles of first line treatment Includes 'Look', 'Listen', 'Feel' and 'Measure' icons |
| abc of nursing assessment: Medical Surgical Nursing Care Karen M. Burke, Priscilla T LeMone, Elaine Mohn-Brown, Linda Eby, 2013-10-03 Medical Surgical Nursing Care 3e has an even stronger focus on the professional Practical nursing program and is a key component in the LPN/LVN series at Pearson. It has a clear and readable writing style, it provides a strong foundation for understanding common disorders that affect adults. Opening units of the book focus on concepts, issues, and foundational knowledge. The units that follow focus on common diseases and disorders organized by body system. Each unit begins with review of the system’s structure and function, nursing assessment, and commonly used diagnostic tests for disorders of that system. To facilitate learning, disorder-specific content follows a consistent pattern, beginning with discussion about the disorder, its risk factors, causes, effects on the body, manifestations, and possible complications. Because nurses are integral members of the healthcare team, interdisciplinary care sections include nursing implications for medications, nutritional therapies, surgery and other treatments, including complementary therapies. Each disorder concludes with nursing care, including priorities of care, health promotion, assessment, nursing care measures, and a section addressing continuity of care to home or the community. This text provides more depth in common disease processes, their treatment, and related nursing care. Although organized by body systems for clarity, the book retains a nursing focus throughout. Rationales are provided for nursing interventions to help the student understand the “why,” not just the “what.” |
| abc of nursing assessment: Pocket Guide for Nursing Health Assessment Sharon Jensen, 2011 This full-color spiral-bound pocket guide provides quick access to all aspects of the nursing health history and physical examination. It includes key topics and questions for health promotion, common symptoms, and sentinel symptoms requiring immediate medical intervention. This clinical guide is a perfect companion to Jensen's Nursing Health Assessment: A Best Practice Approach. |
| abc of nursing assessment: Health Assessment in Nursing Janet Weber, Jane Kelley, Ann Sprengel, 2009-10-01 Specifically designed to match the content in Health Assessment in Nursing, Fourth Edition, this lab manual will help students practice and apply the information they learn in their physical assessment course. |
| abc of nursing assessment: Passing Your Advanced Nursing OSCE Helen Ward, Julian Barratt, Navreet Paul, 2009 Aimed at advanced nursing students preparing for advanced clinical practice competence OSCEs, this book provides step-by-step instructions on performing well in OSCE scenarios. |
| abc of nursing assessment: EBOOK: Introduction To Mental Health Nursing Nick Wrycraft, 2009-08-16 This is a comprehensive and reader friendly text that offers students a great introduction and insight into the modern world of mental health nursing. The quotes from students and practical activities engage the reader and enhance application of theory to clinical practice and educational development. Students will benefit from the guidance and support this book offers to complement their nurse education. Lisa King, Senior Lecturer in Mental Health Nursing, The University of Chester, UK Full of insights into what it's like to be a mental health nursing student, including direct quotes from current students! This engaging new textbook provides a student focused introduction to the main issues and themes in mental health nursing. The book requires no previous knowledge and the content has been carefully chosen to reflect the most significant aspects of this important and rewarding area of nursing. The book includes specific chapters on: Social inclusion and the Ten Essential Shared Capabilities. Mental health promotion Mental health at different stages of the life course Physical health issues in mental health settings Mental health law Therapeutic interventions, specifically Cognitive Behavioural Therapy (CBT) and psychoanalytic/psychodynamic approaches The concept of recovery Scenarios and exercises are used to demonstrate integration of theory and practice. These can be easily linked to your placement experience and overall learning and development. Readers are encouraged to develop an analytical and investigative approach to their studies. Other important areas covered in the book include the National Service Framework (NSF) for Mental Health, the Care Programme Approach (CPA) and the Tidal Model of mental health nursing. Introduction to Mental Health Nursing is the perfect introduction for all nursing students with an interest in a career in mental health nursing. Contributors: Geoffrey Amoateng, Amanda Blackhall, Alyson Buck, David A. Hingley, Richard Khoo, Mark McGrath, Mary Northrop, Tim Schafer, Allen Senivassen, Julie Teatheredge, James Trueman, Henck Van- Bilsen, Steven Walker, Steve Wood. |
| abc of nursing assessment: Health Assessment Jill Fuller, Jennifer Schaller-Ayers, 1994 |
| abc of nursing assessment: Assessment in Psychiatric and Mental Health Nursing Philip J. Barker, 2004 This bestseller has been updated to reflect new concepts and ideas. The assessment of mental health problems is vital to the successful planning and treatment for people suffering from them. This book provides a step-by-step guide of how to conduct this assessment, giving student nurses a humanistic perspective on the subject. New material in this second edition includes person-centered assessment and care planning, and culture and culturally-appropriate assessment and care planning. |
| abc of nursing assessment: Risk Assessment and Management in Mental Health Nursing Phil Woods, Alyson M. Kettles, 2009-04-13 Risk assessment and management is a core element of mental health practice, and all nurses need to be aware of the risks surrounding them and their patients in order to create a safe working environment. This timely and accessible text explores how nurses can enhance their skills, and improve their practice so that risk is assessed and managed safely and effectively. Risk Assessment and Management in Mental Health Nursing explores issues including context and definitions of risk, risk assessment tools and techniques, strategies for preventing risk situations, suicide, self-harm, neglect, forensic aspects of risk, substance misuse, ethical considerations, , victimology, risk to others and risk to self. Special Features: Written in the context of latest policy developments such as the National Service Frameworks Discusses the role of the mental health nurse in the assessment and management of risk Explores an increasingly important and timely subject in mental health practice Practical focus, with case studies throughout Written by experts in the field |
| abc of nursing assessment: Fast Facts for the Medical- Surgical Nurse Maggie Ciocco, MS, RN, BC, 2014-08-26 Written for registered nurses in orientation, this concise, user-friendly resource provides a complete picture of all components of excellent patient care on a busy medical-surgical nursing unit. It covers assessment, key clinical skills/procedures, and documentation of care in an easily digestible, bulleted format. Time-tested guidance about new nurse orientation to professional practice includes ìproven pearls for success.î Content is current and evidence-based, and reinforces previously mastered skills in ìkey points to rememberî sections. The theme of ìthe big pictureî of patient care is a consistent thread throughout. Clinical chaptersóorganized by body system for easy reference--present common conditions seen in medical-surgical nursing and unit emergencies, along with focused assessments, lab work overview, related procedures and skills, a documentation guide, and common medications including those for pain management. Chapters also cover pre-operative and post-operative care for all conditions. Several ìmust-have sectionsî include an orientation guide describing what new nurses can expect as they embrace their new role. This section addresses co-workers and supervisors, finding a mentor, hourly rounding, HIPAA reminders, and telephone skills/customer relations. Another section is devoted to all aspects of infection control, and an appendix provides a wealth of resources and supporting information of particular value to the new nurse. Key Features: Provides concise, user-friendly, evidence-based guidance about the ìwhole pictureî of nursing on a medical-surgical or sub-acute unit Presents a unique orientation section offering ìproven pearls for successî Contains focused assessment guides, skills overview, documentation tips, and medications for common medical-surgical conditions and emergencies Addresses pre- and post-operative care and pain control Covers important protocols regarding infection control |
| abc of nursing assessment: Care Planning Benita Wilson, Andrea Woollands, David Barrett, 2014-05-01 Why is care planning important? How can you use care planning effectively in your own practice? Being able to plan the care of patients is one of most important aspects of a nurse’s role. Using an interactive approach, this book explores the reasons why care planning is so important and explains the theory behind the practice, providing a step-by-step guide to assessing patients, diagnosing problems, planning goals and interventions, and evaluating progress. |
| abc of nursing assessment: The Nursing Process Helen Yura, Mary B. Walsh, 1978 Die Schritte des Pflegeprozesses werden in den einzelnen Kapiteln ausführlich dargestellt, dabei wird unterschieden zwischen Inhalten des Assessment und Art und Weise der Erhebung; diese Einteilung wird bei der Erstellung der Planung beibehalten. Im Kapitel Implementing a plan of care beziehen sich die Ausführungen auf notwendige Kompetenzen der Pflegekraft sowie auf Rahmenbedingungen der Arbeit (Pflegesystem). Die Evaluation des Pflegeprozesses befasst sich mit der Frage, was, wie, wann usw. überprüft werden soll. Hier liegt das Augenmerk auf der Frage, wie festgelegte Ziele überprüft werden können. |
| abc of nursing assessment: Emergency Triage Kevin Mackway-Jones, Janet Marsden, Jill Windle, 2014-02-03 The Manchester Triage System (MTS) is the most widely used triage system in the UK, Europe and Australia, with tens of millions of patients being processed through hospital emergency departments. It is also used in hospitals throughout Brazil. Emergency Triage is the core text for the MTS, which utilises a risk averse system of prioritisation for patients in all unscheduled care settings. As such, it is an essential text for all emergency department staff using the MTS, in particular triage nurses. The book is both a training tool and a reference for daily use in the Emergency Department and prehospital settings. This edition features revised protocols that reflect new approaches to prioritisation, with accompanying revised flowcharts - the core part of the book. Table of Contents Presentation flow charts index 1: Introduction 2: The decision-making process and triage 3: The triage method 4: Pain assessment as part of the triage process 5: Patient management, triage and the triage nurse 6: Auditing the triage process 7: Telephone triage 8: Beyond prioritisation to other applications This Edition was updated in 2023 to Version 3.8. |
| abc of nursing assessment: Advances in Patient Safety Kerm Henriksen, 2005 v. 1. Research findings -- v. 2. Concepts and methodology -- v. 3. Implementation issues -- v. 4. Programs, tools and products. |
| abc of nursing assessment: Emergency Nursing at a Glance Natalie Holbery, Paul Newcombe, 2016-03-21 From the publishers of the market-leading at a Glance series comes a wide-ranging and succinct overview of the key concepts of emergency care. Emergency Nursing at a Glance uses the unique and highly visual at a Glance format to convey vital information quickly and efficiently, ensuring that nursing students have access to all the important topics they need for an emergency care placement. This highly visual, easy-to-read guide is the ideal companion for anyone entering fields involving urgent or unscheduled care. •Includes all aspects of emergency care, including trauma, minor injury, triage processes, patient assessment, common emergency presentations, as well as legal, ethical and professional issues. •Covers care of adults, children, and those with learning disabilities and mental health conditions •Presented in the bestselling at a Glance format, with superb illustrations and a concise approach Emergency Nursing at a Glance is an invaluable resource for nursing students, newly qualified nurses and other healthcare professionals working in emergency departments, urgent care centres, minor injury units and walk-in centres. |
| abc of nursing assessment: Patient Safety and Quality Ronda Hughes, 2008 Nurses play a vital role in improving the safety and quality of patient car -- not only in the hospital or ambulatory treatment facility, but also of community-based care and the care performed by family members. Nurses need know what proven techniques and interventions they can use to enhance patient outcomes. To address this need, the Agency for Healthcare Research and Quality (AHRQ), with additional funding from the Robert Wood Johnson Foundation, has prepared this comprehensive, 1,400-page, handbook for nurses on patient safety and quality -- Patient Safety and Quality: An Evidence-Based Handbook for Nurses. (AHRQ Publication No. 08-0043). - online AHRQ blurb, http://www.ahrq.gov/qual/nurseshdbk/ |
| abc of nursing assessment: Clinical Companion for Foundations of Psychiatric Mental Health Nursing Elizabeth M. Varcarolis, 1999-12 |
| abc of nursing assessment: Rapid Assessment of the Acutely Ill Patient Sheila Adam, Mandy Odell, Jo Welch, 2013-03-27 Rapid Assessment of the Acutely Ill Patient sets out the principles and practices needed for early recognition and assessment of patients either at risk of or showing signs of acute deterioration, or those recently relocated from higher levels of care. The focus is on patient assessment, interpretation and evaluation of data, immediate management of significant problems, ongoing and further assessments in order to improve clinical outcomes. Rapid Assessment of the Acutely Ill Patient provides a framework for a systematic initial patient assessment and explores principles of effective assessment. Body systems are considered in order of life-threatening priority following the ABCDE approach, dealing with the assessment and management of airway, breathing, circulation, disability - and everything else; covering topics such as visual, palpatory and auscultatory assessment, use of additional documented information (charts, notes etc), and interpreting diagnostic investigations. Methods to ensure effective communication and team-working are also discussed. Key features Part of the Essential Clinical Skills for Nurses series Aimed at nurses working in wards and specialist departments Explores the assessment skills required for a rapid response to a patient at risk of becoming acutely unwell Enables students and practitioners to develop practical and interpretative skills Provides a framework for assessment and principles of first line treatment Includes 'Look', 'Listen', 'Feel' and 'Measure' icons |
| abc of nursing assessment: Brunner & Suddarth's Textbook of Medical-surgical Nursing Suzanne C. O'Connell Smeltzer, Brenda G. Bare, Janice L. Hinkle, Kerry H. Cheever, 2010 Preparing students for successful NCLEX results and strong futures as nurses in today's world. Now in its 12th edition, Brunner and Suddarth's Textbook of Medical-Surgical Nursing is designed to assist nurses in preparing for their roles and responsibilities in the medical-surgical setting and for success on the NCLEX. In the latest edition, the resource suite is complete with a robust set of premium and included ancillaries such as simulation support, adaptive testing, and a variety of digital resources helping prepare today's students for success. This leading textbook focuses on physiological, pathophysiological, and psychosocial concepts as they relate to nursing care. Brunner is known for its strong Nursing Process focus and its readability. This edition retains these strengths and incorporates enhanced visual appeal and better portability for students. Online Tutoring powered by Smarthinking--Free online tutoring, powered by Smarthinking, gives students access to expert nursing and allied health science educators whose mission, like yours, is to achieve success. Students can access live tutoring support, critiques of written work, and other valuable tools. |
| abc of nursing assessment: Psychiatric and Mental Health Nursing in the UK Katie Evans, Debra Nizette, Anthony O'Brien, Catherine Johnson, 2019-06-28 Psychiatric and Mental Health Nursing in the UK is an adaptation of Australia and New Zealand's foremost mental health nursing text and is an essential resource for both mental health nursing students and qualified nurses. Thoroughly revised and updated to reflect current research and the UK guidelines as well as the changing attitudes about mental health, mental health services and mental health nursing in UK. Set within a recovery and patient framework, this text provides vital information for approaching the most familiar disorders mental health nurses and students will see in clinical practice, along with helpful suggestions about what the mental health nurse can say and do to interact effectively with patients and their families. - Gives readers a thorough grounding in the theory of mental health nursing. - Case studies throughout the text allow readers to understand the application of theory in every day practice. - Includes critical thinking challenges and ethical dilemmas to encourage the reader to think about and explore complex issues. - Exercises for class engagement complement learning and development in the classroom environment. |
| abc of nursing assessment: Fundamentals of Nursing Christy Bowen, Lindsay Draper, Heather Moore, 2024-09-16 Fundamentals of Nursing aligns with the outcomes and competencies of a nursing fundamentals course. It is designed to provide students with the foundational knowledge and practical expertise essential for delivering holistic and patient-centered care. The authors emphasize the application of clinical judgment across diverse healthcare environments, ensuring readiness to deliver high-quality, compassionate care in an inclusive and supportive manner. Composed of 43 chapters, Fundamentals of Nursing offers an in-depth exploration of the roles and responsibilities of the nursing profession, the healthcare environment, and the application of critical thinking and evidence-based practice. Fundamentals of Nursing features a variety of engaging and informative resources designed to prepare students for real-world clinical environments. By simulating patient interactions, students develop critical communication skills essential for effective nursing care. Insights from practicing nurses provide real-world perspectives, helping bridge the gap between theory and practice. The offering builds student confidence and competence through its focus on Quality and Safety Education for Nurses (QSEN), inclusion of robust unfolding case studies, and integration of NCLEX practice. This is an adaptation of Fundamentals of Nursing by OpenStax. You can access the textbook as pdf for free at openstax.org. Minor editorial changes were made to ensure a better ebook reading experience. Textbook content produced by OpenStax is licensed under a Creative Commons Attribution 4.0 International License. |
| abc of nursing assessment: Introductory Maternity Nursing N. Jayne Klossner, 2006 This full-color LPN/LVN-level textbook presents maternity nursing using a nursing process framework. Throughout the text are features that help students develop critical thinking skills and apply content to practice—such as nursing procedures, nursing care plans, clinical pearls, patients' and caregivers' stories, critical thinking questions, cultural snapshots, family teaching tips, and over 200 illustrations. Each chapter is followed by an integrated study guide/workbook with NCLEX®-style questions, Critical Thinking: What Would You Do? scenarios including dosage calculations, and Study Activities including Internet activities. Introductory Maternity Nursing is an ideal complement to Hatfield, Broadribb's Introductory Pediatric Nursing, Sixth Edition. Instructors who prefer a combined maternity/pediatric text can use Klossner/Hatfield, Introductory Maternity and Pediatric Nursing. |
| abc of nursing assessment: Orientation Handbook for Nursing Personnel , 1985 |
| abc of nursing assessment: Critical Care Nursing - E-Book Linda D. Urden, Kathleen M. Stacy, Mary E. Lough, 2021-02-18 Winner of the 2nd-place American Journal of Nursing Book of the Year award in emergency/critical care nursing for 2021! **Selected for Doody's Core Titles® 2024 with Essential Purchase designation in Critical Care** Prepare for success in today's high acuity, progressive, and critical care settings! Critical Care Nursing: Diagnosis and Management, 9th Edition helps you understand and apply critical care nursing principles and concepts to clinical assessment, diagnostic procedures, and therapeutic management. Known for its comprehensive coverage, this leading textbook uses a logical, body systems organization to address the care of patients with physiological alterations. New to this edition are illustrated Patient-Centered Critical Care features aimed at humanizing the ICU as well as Next Generation NCLEX® Exam–style case studies to help you further develop your clinical judgment skills and prepare for the latest nursing licensure exam. Also ideal for CCRN® and PCCN® exam preparation, this book is a one-stop resource on the concepts and skills required for critical care nursing! - Time-tested, high-quality content addresses all aspects of today's high acuity, progressive, and critical care nursing. - Consistent organization within each body-system unit provides an efficient framework for learning, for CCRN® and PCCN® certification preparation, and for reference in clinical practice. - Comprehensive, evidence-based content is highly referenced and includes internet resources for further research and study. - Enhanced Quality and Safety Education for Nurses (QSEN) integration links text content to QSEN competencies, through the addition of QSEN-related questions in case studies, QSEN-labeled features and boxes, QSEN content icons, and highlighted QSEN information. |
| abc of nursing assessment: Nurse as Educator Susan Bacorn Bastable, 2003 This book is designed as a safety and health primer for individuals in the educational, workplace, and public sectors.If you are a safety education instructor, environmental health instructor, or occupational safety and health instructor, this may be the book you're looking for.Other professionals who should consider using this text include industrial firefighters, industrial engineers, safety engineers, respirator users, asbestos removers, lead-based paint and hazardous waste removers, chemical workers, and human resource managers. |
| abc of nursing assessment: Emergency Nursing Care Gary Jones, Ruth Endacott, Robert Crouch, 2002-11 The field of accident and emergency nursing is a fast moving one. This comprehensive textbook is aimed at both the qualified or trainee nurse who has specialised, or is thinking of specialising, in accident and emergency care. The authors and editors are all experienced nurses and nurse-educators who aim to provide easy to read, and easy to find information about procedures, conditions and nursing skills that a newcomer to the field may not be familiar with, or with which he or she has only a superficial knowledge. Throughout the text, much use is made of illustrations, tables and boxes of key information, and a comprehensive list of references is included at the end of each chapter. |
| abc of nursing assessment: Nursing the Acutely Ill Adult David Clarke, Alison Ketchell, 2017-09-16 Nurses in all areas of clinical practice must be able to recognise, assess and manage changes to a patient's condition. With a strong focus on pathophysiology, the comprehensive new edition of this essential textbook retains the case study approach that made the first edition so popular with students and educators alike. Offering further reading resources and definitions of key terms to aid learning it develops nurses' key skills such as identifying and explaining the pathophysiology of sepsis; recognising and managing hypovolaemic shock; assessment and management of cardiovascular, neurological and traumatic injury; and understanding priorities in initial stroke assessment and management, including nursing care following administration of a thrombolytic drug. Written by contributors from a range of clinical and academic backgrounds, Nursing the Acutely Ill Adult is essential reading for all students within the adult branch of nursing, a comprehensive book guide to understanding the common signs and symptoms related to serious acute illness in adults. New to this Edition: - A chapter on strokes to account for the significant changes that have occurred in the management of the hyper-acute phase of stroke - A chapter on sepsis in response to feedback from students, staff and lead clinicians - Case studies revised to accommodate a wider variety of settings - Covers possible interventions for problems related to diabetes, chronic respiratory disease and renal disease |
| abc of nursing assessment: Oxford Handbook of Learning and Intellectual Disability Nursing Owen Barr, Bob Gates, 2018-11-22 Fully updated to meet current guidelines and standards of practice, this handbook provides concise and practical information for intellectual and learning disability nurses. Small enough to slip into a bag for daily reference but still highly detailed, this is an invaluable resource for everyone working in the field. |
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