Hi and welcome to Nursing School Explained. This video is the first video in the series about
the different steps of the nursing process and the first step is always assessment. So
let's take a look at this. In the assessment phase we gather information about the patient.
Now we have to distinguish between subjective and objective data. Subjective data is anything that
the patient tells us about. So basically it's their subjective information, anything that they share
with us and, of course, we're going to have to probe and ask closed- as well as open-ended questions
to get the answers that we need to determine what we need to do for this patient and their
care. Now the objective data is basically all the observations that we do and there are several
things that are included in this objective data. So it first starts with the chief complaint or
sometimes this is has a little bit of a negative connotation so some people call it the reason
for seeking care. And then we go into the history of the present illness. So what happened
that brought the patient to the hospital that that contributed to the reason for seeking care.
Number three would be a review of systems, where we systematically approach all the
different body systems to determine how might other symptoms for other body parts be related ,
to the patient's reason for seeking care. And then we have to look into their past medical history, past
surgical history, allergies, current medications, family history as well as psychosocial history.
Again, all this is objective data that we'll ask the patient about and then we have our physical
assessment which is one of the most important parts of gathering data in the assessment phase.
And that, of course includes, vital signs and for the physical assessment we always approach the
patient in a methodical head-to-toe way. That way we don't miss anything and so
some students get nervous because they might, you know, forget to do one of the other things
Now the order of operation doesn't really matter. So, for example, whether you listen to the patient's
anterior or posterior lungs first doesn't really matter. If you listen to the heart first and the
lung second, vice versa, it doesn't matter as long as you cover that, right? And if you always approach
the patient in the same systematic way, you will not forget to assess an important part and miss
gathering some of this important data we're trying to accomplish here.
For physical assessment we also want to make sure that we have a focused assessment.
So we don't necessarily assess all the different, very intricate details of the patient every
single time we assess them, but we make it focused, referring back to their reason for seeking care
and the history of their present illness. So, for example, if they're there for a respiratory
problem we're going to focus on the respiratory system, but that also means we have to assess
their um circulatory status, their orientation because oxygenation has a lot to do with those. And
those signs and symptoms might be apparent if the patient is not doing well with their oxygenation.
And then the other important objective data are labs, so any kind of lab values that we can
gather, as well as diagnostic tests such as chest x-ray, MRIs, CAT scans, echocardiograms, and so forth.
Now if we look at the specific example here: so if we say the patient's chief complaint, the reason
for seeking care, is shortness of breath. So they're telling us "I am short of breath and that's why I'm
here." Okay, history of the present illness - how long have you been short of breath, when did it start, do
you have any other associated symptoms?Review of systems, such as chest pain, referring back to the
cardiovascular system, do you have any palpitations, do you have any headaches, do you feel dizzy? Then
of course we're going to assess the patient's mental status to see are they perfusing well? Do
they get enough oxygen to the brain? As well as, of course, assess their lung sounds, their respiratory
rate, and all these assessments as well as for circulation, we're going to listen to the heart
sounds, measure the peripheral pulses, check their skin color, their cap refill, all these things that
we can assess to see are they oxygenating well now that they're complaining of shortness of breath.
And then, for example, for past medical history and surgical history they might tell us "Oh yeah, I have
a history of hypertension, congestive heart failure, I smoke and I'm married." So those are important
things to note here. Now what's also important here is that we also only ask for pertinent
information. And sometimes students have a little bit of a difficult time to find out what's
pertinent. So in this example of the shortness of breath this data here with the history of
hypertension, congestive heart failure, being a smoker, and being married, is important. What's not
important is that the patient had an appendectomy at the age of six. That does not really
have any relationship to their shortness of breath. It might be noted somewhere in the past surgical
history but really it is not pertinent information, it does not somehow relate back to their shortness
of breath. And then we're going to ask them about their medications, so maybe they're telling us
they're taking Lasix and Lisinopril, so maybe your your light bulb should be going off
saying: okay, I know the patient is taking these two medications, I know they work on the patient's
fluid volume status, they work on their kidneys, they have something to do with potassium, so now
let me see if I can look at their labs. So a CBC would tell us about the hemoglobin and hematocrit.
So if they have a low H&H, they might feel short of breath because now they only have half the tank
full, so that means they have decreased blood cells available to perform the oxygen oxygen
carrying into the different cells and so now, of course, they're going to feel short of breath.
We're going to assess the metabolic panel to look at their electrolytes and also their
kidney function, because we know with CHF they could be in fluid volume overload and affecting
their kidney function. We might want to look into a BNP to assess their cardiovascular status and
the status of their congestive heart failure, or a D-dimer if you were worried about clotting.
And then other diagnostic tests that might be a chest x-ray, an EKG if they're complaining
of chest pain, palpitations, and especially given the history of congestive heart failure.
And then like maybe an echocardiogram to look at their heart in a little bit more detail.
Now, if this here is a little bit too complicated for you, depending on where you are in your in your
nursing career, don't worry about it, you start making these connections as you move on and
through your nursing program, but the important part here is that we need to look at all these
details and refer it back to the patient's chief complaint, the reason for seeking care
but to really take all this into consideration in the assessment phase. Because if we don't gather
all this data during the assessment phase we might not think to check a BNP or a D-dimer, or an EKG
and then we're going to miss an important part of the assessment data and then we're
going to miss identifying a problem that the patient might have and they will not get better.
Now once we've accomplished gathering all our data here by questioning the patient about all
these things and performing our physical assessment, then we can move on into phase
two of the nursing process, which is the problem identification, prioritization of the problems
also known as nursing diagnosis. Now depending on where you are in your program, what they prefer
to use you might still be using nursing diagnosis, although it's a little bit outdated, but what you
call it doesn't really matter. What matters is that now you've gathered all this data and you
need to prioritize what you're going to focus on with your patient to get them well. Now watch
the next video on where I go into the details into the problem identification and prioritization
so you can learn a little bit more about that. Thanks for watching Nursing School Explained!