Shift Assessment In Nursing

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Introduction In the past century, nursing profession has evolved tremendously in all over the country. Health care is changing rapidly to create collaborative working environment with modern technology. Nurses is first line member together with doctor, pharmacy and other health care save and improve patient lives. Nurses are those who independently provide care for patients, alert other care professional about patient abnormalities, delivery of holistic care for patient, asses and monitor patients closely, determine patient need and preserve patient health. One part of routine job and major in nursing role is health nursing assessment. Assessment is an integral component of the nursing role. Assessment mainly link with daily routine work related…show more content…
An admission assessment is assessment done by the nurse in charge ideally upon preadmission. An admission assessment should complete within 24 hours of admission in hospital. It is a comprehensive assessment including general appearance on admission, physical examination, patient history, family history and vital sign taken on admission period. While shift assessment observe during every shift since admission, if patient condition changes at any time during shift and information will use to plan a nursing care. Shift assessment usually documented in assessment flow sheet and keep with patient records. Shift assessment includes airway, breathing and circulation. Airway assessment usually assesses on patient secretion, artificial airway, noise and cough. Air entry and movement, oxygen requirement, work of breathing, ventilator dependent and breath sound usually assess in breathing assessment. In circulation, pulse rate and rhythm, peripheral temperature and capillary refill time usually assess. Focused assessment is a specific nursing assessment address related body system with presenting problem or other concern. It is response by changing status of health, need determine progress actual health problem or potential and presentation of episode problem. It involves one or more system in human body example respiratory, renal, cardiovascular, and…show more content…
Collecting data phase start when patient admitted till discharged. Data was collect by two ways via direct or indirect data. Data from patients or family patient are direct data while data from medical or nursing report, diagnostic laboratory studies and other significant source are indirect data. Primary resource is data which collect from patient. Mean while data obtain from family, relative, friends, care giver and written records such as past clinical records, laboratory or transfer medical summaries from other hospital are group in secondary data. Second validating data is an important and essential data help in avoid making false assumptions, missing information, misunderstanding situation and conclusion. Third phase organizing data is clustering data by critical thinking help to identify problems in different ways. Identifying patterns are fourth data important after third phase to begin some initial impression of patterns. Final phase of assessment is reporting data will expedite diagnosis and treatment. Health care should report abnormal suspect, compare data with standard normal limit and remember the normal limit vary from a person to another person and difference

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