Red Cross Nursing

One of the essential duties of a nurse, or a certified nursing assistant, in the hospital ward is to properly assess, collect and record details of a patient admitted for treatment, and also properly document the same for reference by other nurses as well as the doctors attending the patient. A nurse should maintain the details in a proper manner such that it will become part of medical history of the patient and will be a guide for treating the patient.

As soon as the patient is admitted for in-hospital treatment to his or her physical illness and allocated a room or a bed in the ward, it is the responsibility of the nurse in charge of the ward at that time to collect and record the basic details about the patient apart from the name, age and the nature of illness.

The nurse should assess the conscious level of the patient when admitted for treatment. The nurse should also assess the mood or the comfort level of the patient at the time of admission. These can be gauged from the way the patient presents himself or herself. If in doubt, it is advisable to get it confirmed and documented.

The CNA should next look for the vital signs as well as tissue perfusions and make a note of the conditions of the same. Enquire the patient’s bowel and urinary movements and also enquire whether the patient has any problem in moving freely around without any assistance. If he or she has some problems in free movement, then the entire body needs to be inspected to find out the pressure areas that might be the cause for pain.

The nurse should also make note of the appetite of the patient as well as acceptability of the food provided in the hospital for the patient.

The look and appearance of a person determines the state of his or her health condition to a great extent. However, for the sake of physical assessment from the medical point of view, a nurse has to look at each and every aspect of the body in a critical manner to get a clear understanding or assessment of the person’s state of health.

The Cephalocaudal approach has outlined the major aspects of physical assessment each nurse should carry out for each and every patient visiting the doctor for treatment.

The nurse, as part of the assessment of skin of a person, is expected to look at the following important aspects:

• Color of the skin
• Moisture of the skin
• Temperature
• Texture
• Mobility
• Turgor
• Edema, and
• Lesions

The nurse should take into consideration the genetic norm as well as the race to which the person belongs, while assessing the color of the skin. If the nurse figures out any abnormalities in the skin, not in line with the race or genetic norm, then it might be due to the impact of jaundice, pigment changes, increased vascularity, pallor, cyanosis and / or redness, and it might warrant further assessment.

With regard to the moisture of the patient’s skin, the nurse should take into account the climatic conditions as well as temperature in the region while determining the normal state of moisture content in the skin. The skin should look for any abnormalities in moisture content, such as excessive oily content, excessively dry content, or clammy, and should make note of the same, if found.

The texture of the skin also reveals quite a number of details about the patient. An aged person’s texture might have wrinkling apart from being thinner. A dry or rough texture in skin is an abnormality and needs further assessment.

The nurse should also look for the turgor of the skin. If the dorsal part of the palm or a part of the arm, if pinched, returns to the normal state almost immediately, then the turgor of the skin is said to be normal. If there is any delay in returning to normalcy, then it must be construed as an abnormal feature of the skin and needs further introspection or treatment.