What are The Rationale of Nursing Assessements ?

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Acquiring the most basic details to the most crucial ones about the  patient’s  aspects, involving his physiological, psychological, social and spiritual needs, has to be carried out during the Nursing Assessment.

When the rotation of shifts is involved the complete patient’s case file has to be studied thoroughly, the Doctor’s Notes and the  Nursing handover notes given by the nurse on duty in previous shift  with details about the health status specifically the drug dosage given, current physical status of the patient post surgery, the requirements of diet, the risk factors, the past medical history including his and family's medical  & social history, etc. has to be taken up very carefully and should be put to highest levels of scrutiny.

Rationale for the nursing assessment is to identify the problems that are and can be faced by the patient during his stay in the hospital. It enables the nurse to get a clear understanding about the patient’s status, as well as it helps create a rapport with the patient and his relatives. It provides a bird’s eye view to the physical and mental well being of the patient, and there by helps in decisions of management of illness, facilitated by providing adequate drug dosage, diet, life saving facilities, and other relevant needs.

In concordance with the case the Nursing assessments required will be:

CLINICAL ASSESSMENT AND CARE PLAN (“Protocol ICU/Cardiac,” 2010):

A. Circulation 1. BP, Pulse, & respiration Assessment, every 15 minutes X 1 hour, then in every 30 minutes X 2 hours, then every four hours. Monitoring of BP via arterial line if present. 2. Monitoring temperature every 4 hours while awake. If temperature is >101ºF, monitoring every 2 hours. If temperature is >102ºF, notification should be provided to Head Nurse/ the Doctor on Duty. 3. Circulation, sensation, motion and pulses to both feet to be assessed every 15 minutes X 1 hour, then every 30 minutes X 2 hours, then every 1 hour. If patient is asleep, assess per unit protocol.

4. Bleeding or Hematoma to be assessed with sheath and/or closure device for every 15 minutes X 1 hour, then every 30 minutes X 2 hours, then every 1 hour X 2 hours. Dressing areas and time on all hematomas to be outlined. In case of presence of hematoma and is increasing in size, frequency of assessment to be increased to every 15 minutes. 5. 12-Lead EKG/ECG should be performed on admission to the unit and in a.m. with copies on chart. 6. Recurrence of chest pain to be assessed. 7. Maintain Heparin, ReoPro, Integrilin and/or any other Drug Infusion per doctor’s order. Monitoring of PTT and platelet count should be done as ordered. 8. Neuro status and mentation to be assessed at 2-4 hours. 9. It should be ensured that the patient remained on bedrest for 6 hours after the sheath is removed.

It should be taken care of that after 6 hours of sheath removal, Patient may turn in bed, the Bed may be elevated to 45° and the affected lower extremity can be bent slightly.

After 6-18 hours post sheath: Bed rest should be continued primarily and the patient may sit on edge of bed and bedside commode with help can be used. After 18-24 hours post sheath removal, the patient should ambulate in room and the can exercise bathroom privileges and sit in bedside chair. After 24-72 hours post sheath, the patient is fully ambulatory and can perform all non strenuous routine activities.

B. In case of development of Hematoma following should be applied:

1. Application of direct pressure just above arterial site if bleeding continues.

2. Application of pressure dressing with Elastoplast and 5 lb sandbag.

3. Application of Femostop as per protocol.

4. Assessment of frequency for changes over time.

C. In case any of the following is noticed the nurse should report it to the consultant/ doctor on duty: 

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