NURSING ASSESSMENT INCLUDING

WATERLOW PRESSURE/PRESSURE SORE​

PRESENTED BY

NURSE OBUNADIKE EVELYN

Definition

The nursing assessment means gathering information concerning the

patient's individual physiological, psychological, sociological, and
spiritual needs. It is the first step in the successful evaluation of a patient.
Subjective and objective data collection are an integral part of this process.
Part of the assessment includes data collection by obtaining vital signs
such as temperature, respiratory rate, heart rate, blood pressure, and pain
level using an age or condition appropriate pain scale.

3
• . The function of the initial nursing assessment is to identify the
assessment parameters and responsibilities needed to plan and deliver
appropriate, individualized care to the patient
• This includes documenting:
• Appropriate level of care to meet the client's or patient’s needs in a
linguistically appropriate, culturally competent manner
• Evaluating response to care
• Community support
• Assessment and reassessment once admitted
• Safe plan of discharge

4
• The nurse should strive to complete:
• Admission history and physical assessment as soon as the patient
arrives at the unit or status is changed to an inpatient
• Data collected should be entered on the Nursing Admission
Assessment Sheet and may vary slightly depending on the facility
• Additional data collected should be added
• Documentation and signature either written or electronic by the
nurse performing the assessment

5
• Therapeutic Communication Techniques Used to Take a Good
Nursing Assessment
• Multiple strategies are employed that will include:

• Active, attentive listening

• Reflection, sharing observations
• Empathy . Share hope
. Share humor . Provide information
. Clarification
• Summarizing

6
• A detailed nursing assessment is a comprehensive examination
and evaluation of a patient's physical, psychological,
sociocultural, and spiritual health. A detailed nursing assessment
includes:
• Biographical Data:
– Name, age, gender, and contact information.
– Time admitted, how admitted, From where?
– Religion, Was patient accompanied on admission? If yes name and
relation.
– Next of kin, Relation and contact. – Primary language spoken. –
Reasons for coming to the hospital(Patient own words)

7
• Health History:
– Past medical history, including chronic illnesses, surgeries, and
hospitalizations.
– Current Medication history, name, frequency and when last was it taken.
If the patient is in possession of his or her drugs the nurse will tell the
patient to deposit it or instructed to send it home. Count the number of
medications in front of the patient , write it down , give a copy to the
patient, take the other copy with the drugs to the pharmacy
– Ask patient for family medical history.

8
• Social History:
– Living situation (e.g., alone, with family, in assisted living).
– Occupation and work environment.
– Substance use (alcohol, tobacco).
– Sexual history and reproductive health.
– Support system and social support.

• Vital signs: Temperature recorded in Celsius, heart rate,

respiratory rate, blood pressure, pain level on admission,
oxygen saturation.

9
 Pain Assessment
Pain, or the fifth vital sign, is a crucial component in providing the
appropriate care to the patient. Pain is anything the patient or client states that
it is to them. Systematic pain assessment, measurement, and reassessment
enhance the ability to keep the patient comfortable. Improvement of
communication regarding pain assessment and reassessment during admission
and discharge processes facilitate pain management, thus enhancing overall
function and quality of life.
In assessment of pain, the nurse will ask the patient
- the pain score,
- location of the pain,
- character (is it arching, dull, sharp or burning).
- The acuity (is it acute which is less than 6 weeks or chronic which
is more than 6 weeks)
- The modifying factors (what increases or decreases the pain)
- The nurse will make use of pain reassessment scale to evaluate
the pain

11
 ​ llergies:
A
• Ask patient if he or she is allergic to Medications, foods, blood
transfusion and environmental; nature of the reaction and
seriousness; intolerances to medications;
• Document everything in your SBAR

12
• Valuables: Collect, record and send to appropriate safe storage or send
home with family following any institutional policies on the secure
management of patient belongings; provide and label denture cups. If
none was handed over to the nurse, the nurse will still have to
document that no patients belongings was collected.
• Orientation: Take patient around the room, bathroom, waste
management, nurse call bells, light controls, side rails, bed controls,
give handbooks, television, visitation policy and no smoking policy.

13
• Impairments/Disabilities: Check for impairments which includes
impaired hearing and vision. Assess if patient can perform ADLS, write
or read. Look out for hearing aids, glasses, contacts, dentures etc.
• Ability to perform ADLS: Check daily activity limits and need for
mobility aids. ADLS includes bathing, dressing, eating, walking, stair
climbing and toilet use. Close monitoring is required if the patient can
not perform these ADLS to avoid falls during the shift.

14
• Psychosocial status: Evaluate need for a sitter or video
monitoring, check for any signs of agitation, restlessness, anxiety,
anger, aggression, cheerfulness, hallucinations, depression,
suicidal ideations, or substance abuse. Patients with such requires
close monitoring to avoid self harm
• Advanced directives: These are legal documents that
communicate a person's wishes about health care decisions in the
event the person becomes incapable of making health care
decisions.

15
• Anyone can wind up hurt or sick and unable to make decisions
about medical treatments. An advance directive speaks for you if
you are unable to, and helps make sure your religious and
personal beliefs will be respected. EG. of advanced directive
DNR form or Do not transfuse blood (Jehovah witness church). It
might be in a copy or file which is collected and kept by the nurse
in the patient case note.

16
Sleep and sleep routine history:
Ask patient if there is problem involving his or her sleep.
Is there difficulty falling asleep?
Does patient rest after sleep?
What helps them sleep?
Ask patient time he or she sleeps
Number of hours?
Number of pillows
Naps

17
Nutritional Risk Screening: Has food intake declined over the past 3
months due to loss of appetite? Difficulty in chewing? Difficulty in
swallowing? Recent unexplained weight loss or gain during the last
months? Any special diet? Pallor, sunken eyes, dehydration, anorexia?
Vomiting, diarrhea, edema? Newly diagnosed diabetic/hypertension? Any
tube feeding? Hair change/skin change?
NOTE: Screen score (total max 21 points)
18 points or greater - Normal, not at risk
17 points or below – Possible malnutrition, inform dietician for further
evaluation and assessment

18
Fall risk assessment:
Any history of falling? Any dizziness, parkinson, neuropathy,
osteoarthritis, hypertension? Ambulatory aid? Either
cane/cruthes/walker/ Furniture/ None/ bed rest/ nurse assist? Does
patient have IV access? Is patient impaired, weak? Is patient normal/ on
wheel chair or bed rest? Mental status of the patient- Is patient oriented
to won ability? Or forgets limitations?
0-24 Low risk (Implement low risk fall prevention intervention)
25-44 Medium risk (Implement medium risk fall prevention intervention)
>45 High risk (Implement high risk fall prevention intervention)

19
• The Waterlow /Pressure ulcer assessment: It gives an estimated
risk for the development of a pressure sore in a given patient. The
tool was developed in 1985 by clinical nurse teacher Judy
Waterlow.
• It calculates the estimated risk of pressure ulcers developing in
adults through a simple points-based system using individual data.

20
Waterlow/Pressure ulcer cont”d

The Waterlow scale includes the following factors: Biodata, Age,

built/weight for height BMI, continence, skin integrity, mobility,
appetite, weight loss, tissue malnutrition, neurological deficits,
major surgery or trauma, medications, scores, action required and
nurse details.

21
Transfusion reaction
• Transfusion reaction can be categorized as haemolytic, febrile,
circulatory over load and allergic. The nurse must assess a client closely
for reactions. Sign of an acute reaction include sudden chills or fever,
low back pain, drop in blood pressure, nausea, flushing agitation or
respiratory disorders. Sign of less severe allergic reaction include hives
and itching but no fever.

22
 Nursing Management for Transfusion Reaction

• Stop the transfusion.

• Maintain the intravenous line with normal saline solution through new
intravenous tubing, administered at a slow rate.
• Asses the patient carefully, compare the vital sign with those
from the base line assessment.
• Notify the physician of the assessment findings and implement any
instructions obtained.
• Notify the blood bank that a suspected transfusion reaction has
occurred.
• Send the blood container and tubing to the blood bank for repeat
grouping and cross matching, the identifying tag and number are
verified. 23
 Post Transfusion
• Obtain vital sign and compare with base line assessment.
• Document procedure in patient's medical record using the
• nursing care plan to include finding and tolerance to the
• procedure.
• Monitor patient for response to and effectiveness of the
• procedure.
• Terminate the transfusion
• Discard administration set according to policy procedure

24