NSG 521 MODULE 12 ASSESSMENT OF THE
HOSPITALIZED CLIENT
As a nurse, you are continuously assessing patients. When there are signs of an
emergent, acute, or urgent situation, you perform immediate assessments and
interventions with a team of providers. - Answers - True
Acute and urgent situations such as the following warrant immediate attention and
interventions:
A respiratory rate lower than 8 or greater than 28 breaths/min
An acute change in oxygen saturation below 90% despite oxygen administration
A threatened airway
Acute change in systolic BP to less than 90 mm Hg or a sustained increase in diastolic
BP greater than 110 mm Hg
Acute change in heart rate to fewer than 50 or greater than 120 beats/min
New-onset chest pain or signs of acute myocardial infarction
An acutely cold, cyanotic, or pulseless extremity
Confusion, agitation, or delirium
Unexplained lethargy or acute altered mental status
Difficulty speaking or signs of acute stroke
Acute change in pupillary response
New seizure
Temperature greater than 39.0°C (102.2°F)
Uncontrolled pain
Acute change in urine output less than 50 ml (about 1¾ oz) over 4 hours
Acute bleeding
Suspected severe sepsis (AHRQ, 2013a) - Answers - True
In addition to verbal notification of a deteriorating patient to the provider, most facilities
have escalation protocols. Patients whose condition deteriorates acutely while
hospitalized often exhibit warning signs in the hours before experiencing adverse
clinical outcomes. Rapid response teams are designed to intervene during this critical
period, usually on general medical or surgical wards - Answers - True
After any urgent needs have been addressed, you may then perform the initial
comprehensive hospital assessment (Box 29.3). The admission assessment includes
assessment of the physical, emotional, and mental aspects of all body systems as well
as the environment, cultural, and social issues affecting the patient. This includes the
collection of both subjective and objective data. - Answers - True
The initial patient history and head-to-toe physical examination may take 30 to 45
minutes or longer to complete. Subsequent assessments are shorter because they
focus on problem areas rather than the entire body. It is important to make this initial
assessment comfortable and efficient for the patient. Adapt the assessment to the
,patient in a manner that is professional yet personal and individualized. Allow some time
for documentation of findings and analysis of data. In addition to positive findings, it is
essential to document absence of findings because, in the legal world, "if it's not
documented, it's not done." For example, if the patient develops acute confusion, it is
important to be able to look back in the chart and see "no confusion" to identify this
change in status as significant. In addition, it is especially important to assess for
allergies, devices such as pacemakers, and adverse reacti - Answers - True
A nurse should gather a stethoscope, thermometer, watch with a second hand,
sphygmomanometer or vital signs machine, and pulse oximeter when preparing to
assess a hospitalized patient. - Answers - True
The purpose of safety assessments is to assess the patient's immediate medical
condition as well as potential hazards such as falls, impaired breathing, malfunctioning
equipment or complications from IV lines, and intubation. - Answers - True
Which of the following would be included as components of the admitting assessment
on a hospitalized patient? Select all that apply. - Answers - Abdominal assessment
Upper and lower extremities assessment
Anterior and posterior thorax assessment
General survey
Psychosocial assessment
Neurological assessment
Vital signs
Intake and elimination assessment
Head, face, eyes, ears, nose, mouth, throat (HEENT) assessment
Which of the following are true regarding admitting assessments for hospitalized
patients? - Answers - Because a hospitalized patient is often more ill than a
nonhospitalized patient, the nurse should prioritize data to collect related to the
presenting problems and perform a basic screening of other body systems.
An urgent assessment is warranted for an acute change in heart rate to fewer than 50
beats/minute. - Answers - True
An urgent assessment is warranted when there is an acute change in pupillary
response. - Answers - True
An urgent assessment is warranted for an acute change in heart rate to greater than
120 beats/minute. - Answers - True
An urgent assessment is warranted when acute altered mental status occurs. -
Answers - True
An urgent assessment is warranted when an extremity becomes acutely cold. -
Answers - True
, An urgent assessment is warranted in the presence of confusion, agitation, or delirium. -
Answers - True
Perform a safety inspection of the hospitalized patient and environment, including
equipment. You will often perform this assessment during the change-of-shift rounding
or handoff procedure. The purpose is to assess the patient's immediate medical
condition as well as potential hazards such as falls, impaired breathing, malfunctioning
equipment or complications from IV lines, and intubation. - Answers - True
The initial safety inspection includes the following steps:
Directly observe the patient for breathing, airway, skin color, signs of dyspnea, and
airway secretions.
If the patient is awake, briefly introduce yourself and provide your name and contact
information.
Check that the patient's identification band includes two patient identifiers.
Observe the patient while he or she is lying in bed, sitting in a chair, moving in the room,
and fall risk.
Check that the lighting and call bell are within reach.
Observe for cues of recent events (e.g., suctioning equipment, meals).
Trace tubes to insertion site and check solutions and rates. Check IV fluids and tube
feeding for accurate infusion. Check urinary catheter positioning.
Check that equipment is working properly, alarms are on, bed alarms are on, and
restraints are in place, as necessary. - Answers - True
The nurse should use clinical judgment about which items to include and which to omit
during the admitting assessment.
The nurse must adapt assessment techniques to the individual patient situation.
The nurse will usually document the admitting assessment in a separate area of the
patient medical record, which may include input from other health care professionals.
The nurse should be sure to allow time for validation of problems, mutual goal setting,
and discussion of an action plan. This communicates to the patient that his or her
concerns are well understood and helps establish a trusting and lasting relationship,
which in turn will make it more likely that the patient will agree to the action plan. -
Answers - True
Typically longer, may take 30-45 minutes - Answers - Admitting Assessment
Documentation usually in a flow sheet format - Answers - Shift Assessment
Perform hand hygiene before and after assessment - Answers - Both shift and
admitting assessment
HOSPITALIZED CLIENT
As a nurse, you are continuously assessing patients. When there are signs of an
emergent, acute, or urgent situation, you perform immediate assessments and
interventions with a team of providers. - Answers - True
Acute and urgent situations such as the following warrant immediate attention and
interventions:
A respiratory rate lower than 8 or greater than 28 breaths/min
An acute change in oxygen saturation below 90% despite oxygen administration
A threatened airway
Acute change in systolic BP to less than 90 mm Hg or a sustained increase in diastolic
BP greater than 110 mm Hg
Acute change in heart rate to fewer than 50 or greater than 120 beats/min
New-onset chest pain or signs of acute myocardial infarction
An acutely cold, cyanotic, or pulseless extremity
Confusion, agitation, or delirium
Unexplained lethargy or acute altered mental status
Difficulty speaking or signs of acute stroke
Acute change in pupillary response
New seizure
Temperature greater than 39.0°C (102.2°F)
Uncontrolled pain
Acute change in urine output less than 50 ml (about 1¾ oz) over 4 hours
Acute bleeding
Suspected severe sepsis (AHRQ, 2013a) - Answers - True
In addition to verbal notification of a deteriorating patient to the provider, most facilities
have escalation protocols. Patients whose condition deteriorates acutely while
hospitalized often exhibit warning signs in the hours before experiencing adverse
clinical outcomes. Rapid response teams are designed to intervene during this critical
period, usually on general medical or surgical wards - Answers - True
After any urgent needs have been addressed, you may then perform the initial
comprehensive hospital assessment (Box 29.3). The admission assessment includes
assessment of the physical, emotional, and mental aspects of all body systems as well
as the environment, cultural, and social issues affecting the patient. This includes the
collection of both subjective and objective data. - Answers - True
The initial patient history and head-to-toe physical examination may take 30 to 45
minutes or longer to complete. Subsequent assessments are shorter because they
focus on problem areas rather than the entire body. It is important to make this initial
assessment comfortable and efficient for the patient. Adapt the assessment to the
,patient in a manner that is professional yet personal and individualized. Allow some time
for documentation of findings and analysis of data. In addition to positive findings, it is
essential to document absence of findings because, in the legal world, "if it's not
documented, it's not done." For example, if the patient develops acute confusion, it is
important to be able to look back in the chart and see "no confusion" to identify this
change in status as significant. In addition, it is especially important to assess for
allergies, devices such as pacemakers, and adverse reacti - Answers - True
A nurse should gather a stethoscope, thermometer, watch with a second hand,
sphygmomanometer or vital signs machine, and pulse oximeter when preparing to
assess a hospitalized patient. - Answers - True
The purpose of safety assessments is to assess the patient's immediate medical
condition as well as potential hazards such as falls, impaired breathing, malfunctioning
equipment or complications from IV lines, and intubation. - Answers - True
Which of the following would be included as components of the admitting assessment
on a hospitalized patient? Select all that apply. - Answers - Abdominal assessment
Upper and lower extremities assessment
Anterior and posterior thorax assessment
General survey
Psychosocial assessment
Neurological assessment
Vital signs
Intake and elimination assessment
Head, face, eyes, ears, nose, mouth, throat (HEENT) assessment
Which of the following are true regarding admitting assessments for hospitalized
patients? - Answers - Because a hospitalized patient is often more ill than a
nonhospitalized patient, the nurse should prioritize data to collect related to the
presenting problems and perform a basic screening of other body systems.
An urgent assessment is warranted for an acute change in heart rate to fewer than 50
beats/minute. - Answers - True
An urgent assessment is warranted when there is an acute change in pupillary
response. - Answers - True
An urgent assessment is warranted for an acute change in heart rate to greater than
120 beats/minute. - Answers - True
An urgent assessment is warranted when acute altered mental status occurs. -
Answers - True
An urgent assessment is warranted when an extremity becomes acutely cold. -
Answers - True
, An urgent assessment is warranted in the presence of confusion, agitation, or delirium. -
Answers - True
Perform a safety inspection of the hospitalized patient and environment, including
equipment. You will often perform this assessment during the change-of-shift rounding
or handoff procedure. The purpose is to assess the patient's immediate medical
condition as well as potential hazards such as falls, impaired breathing, malfunctioning
equipment or complications from IV lines, and intubation. - Answers - True
The initial safety inspection includes the following steps:
Directly observe the patient for breathing, airway, skin color, signs of dyspnea, and
airway secretions.
If the patient is awake, briefly introduce yourself and provide your name and contact
information.
Check that the patient's identification band includes two patient identifiers.
Observe the patient while he or she is lying in bed, sitting in a chair, moving in the room,
and fall risk.
Check that the lighting and call bell are within reach.
Observe for cues of recent events (e.g., suctioning equipment, meals).
Trace tubes to insertion site and check solutions and rates. Check IV fluids and tube
feeding for accurate infusion. Check urinary catheter positioning.
Check that equipment is working properly, alarms are on, bed alarms are on, and
restraints are in place, as necessary. - Answers - True
The nurse should use clinical judgment about which items to include and which to omit
during the admitting assessment.
The nurse must adapt assessment techniques to the individual patient situation.
The nurse will usually document the admitting assessment in a separate area of the
patient medical record, which may include input from other health care professionals.
The nurse should be sure to allow time for validation of problems, mutual goal setting,
and discussion of an action plan. This communicates to the patient that his or her
concerns are well understood and helps establish a trusting and lasting relationship,
which in turn will make it more likely that the patient will agree to the action plan. -
Answers - True
Typically longer, may take 30-45 minutes - Answers - Admitting Assessment
Documentation usually in a flow sheet format - Answers - Shift Assessment
Perform hand hygiene before and after assessment - Answers - Both shift and
admitting assessment
