Introduction

In an effort to provide comprehensive care, it’s imperative the nurse understands the importance of an assessment. In any care setting, the assessment is the basis for the care that the individual will receive on a daily basis. This assessment is more than just the physical assessment; it includes many other components that may impact a number of areas of care.

Comprehensive Assessments

A comprehensive assessment is often referred to as an admission assessment or initial assessment. The data in a comprehensive assessment is what ultimately influences the service, support and care plan that’s put into place.

A comprehensive assessment is an assessment that’s generally done upon admission to a healthcare setting by the RN. This assessment usually includes the following:

• Health history
• General survey
• Measuring vital signs
• Assessing body systems
• Psychosocial information

PQRSTU

The nurse may implement a mnemonic to effectively assess the area of complaint, such as the PQRSTU:

• Precipitant/Provocation: What brings it on? What was the individual doing when he or she noticed it? What makes it better? What makes it worse?
• Quality or quantity: How does it feel (sharp, dull, throbbing, cramping)?
• Radiating: Does it spread anywhere else in the body?
• Severity: How bad is it on a scale of 0-10? Is it getting better, worse, or staying the same?
• Timing: When did it first occur? How long did it last? How often does it occur?
• Understanding of the person’s perception of the problem: What do they think it means?

This mnemonic may not be effective for every care recipient during every assessment. It’s one of many tools that can be used during the assessment to ensure accurate information is collected.

Considerations in Preparing for a Physical Assessment

When working with a person who has diminished capacity, regardless of the care setting take extra care to do the following:

• Establish a positive rapport with the person. This will decrease stress for both of you.
• Explain the purpose of the assessment. Reassure the person that the assessment is only to gather information so that an individualized plan can be put into place.
• Obtain and document informed verbal consent for the assessment.
• Maintain confidentiality of ALL data. The nurse should explain what information is needed and how that information will be used.
• Provide privacy from unnecessary exposure. The nurse must assure as much privacy as possible, using drapes or curtains in the room and closing doors.
• Communicate special instructions to the person. Inform the recipient of what will be done, and whether or not they will assist in any way.

When performing a focused assessment on a person with dementia, he or she may become fatigued rather quickly; therefore, the assessment may need to be broken into several sections that can be done at different times.

The person with dementia may not be able to verbally provide information or may not have the facts straight. Nevertheless, the person's view of "what ails them" is important as is the information obtained from a family member or trusted friend. Both are needed for a complete assessment.