NAME 

           : Bamey Ganado

SEMESTER   : 2nd SEMESTER,2023
COURSE        : HUMAN BIOLOGY BL133
 

Comprehensive Patient Assessment in Medical-Surgical Nursing

I. Introduction

Patient evaluation is a vital component of delivering safe and effective care in medical-surgical
nursing. Collecting and evaluating information regarding a patient's health condition, medical
history, and present symptoms, as well as performing a comprehensive physical examination and
interpreting diagnostic test findings, constitute patient evaluation. The information gathered
throughout the patient assessment process is utilized to determine nurse diagnoses, plan and
administer care, and analyze patient outcomes. We will look at the components of a thorough
patient assessment in medical-surgical nursing, as well as the need of continual evaluation in
delivering excellent care, in this lecture.

II. Health History

Taking a thorough health history is an essential component of patient assessment in medical-

surgical nursing. It provides valuable information about a patient's medical history, current
health status, and risk factors for various health conditions. During the health history, nurses ask
questions about the patient's past and present medical conditions, family history, social history,
and medication history. They also gather information about allergies and adverse reactions to
medications.

The types of questions asked during a health history can vary depending on the patient's age,
gender, and presenting symptoms. Common questions include information about past surgeries,
chronic illnesses, and hospitalizations. Nurses also ask about lifestyle factors such as diet,
exercise, and tobacco and alcohol use. Family history questions are also important as they can
provide insight into the patient's risk for certain health conditions.

A thorough medication history is critical in identifying potential drug interactions, adverse

reactions, and medication errors. Nurses should gather information about the name, dosage, and
frequency of medications the patient is taking, as well as any over-the-counter medications,
supplements, or herbal remedies.

Overall, a comprehensive health history provides a foundation for understanding a patient's

current health status and identifying potential risk factors for future health problems. It also
informs the development of nursing care plans based on the patient's specific needs.

III. Physical Examination

NAME            : Bamey Ganado
SEMESTER   : 2nd SEMESTER,2023
COURSE        : HUMAN BIOLOGY BL133
 

A comprehensive physical examination is a critical component of patient assessment in medical-

surgical nursing. It involves a systematic examination of the patient's body systems, including
assessment of vital signs and a head-to-toe assessment. The physical examination provides
important information about the patient's current health status and helps identify any
abnormalities or potential problems.

Techniques for conducting a physical examination include inspection, palpation, percussion, and
auscultation. During inspection, the nurse observes the patient's overall appearance and looks for
any visible abnormalities or signs of distress. Palpation involves touching and feeling various
parts of the body to identify tenderness, swelling, or other abnormalities. Percussion involves
tapping on the body to evaluate the density and consistency of underlying structures.
Auscultation involves listening to the body's internal sounds using a stethoscope.

Assessing vital signs is an important part of the physical examination. Vital signs include
temperature, pulse rate, respiratory rate, blood pressure, and oxygen saturation. These
measurements provide valuable information about the patient's overall health and can help
identify potential problems.

During a head-to-toe assessment, the nurse examines each body system in a systematic manner,
starting with the head and moving down to the feet. This includes assessment of the eyes, ears,
nose, mouth, skin, heart, lungs, abdomen, and extremities. The nurse also assesses the patient's
neurological status, including mental status, orientation, and reflexes.

Overall, a comprehensive physical examination provides important information about the

patient's current health status and helps identify potential problems that may require further
evaluation or intervention.

IV. Diagnostic Tests and Procedures

Diagnostic tests and procedures are commonly used in medical-surgical nursing to help diagnose
and monitor various health conditions. These tests and procedures can provide valuable
information about a patient's health status, including the presence or severity of a disease, the
extent of tissue damage, and the effectiveness of treatment.

Common diagnostic tests and procedures used in medical-surgical nursing include laboratory
tests, imaging tests, and invasive procedures. Laboratory tests may include blood tests, urine
tests, and culture and sensitivity tests to identify the presence of bacteria or viruses. Imaging tests
such as X-rays, CT scans, and MRIs may be used to identify structural abnormalities, tumors, or
other issues. Invasive procedures such as biopsies or endoscopies may be used to collect tissue
samples or to evaluate internal organs.
NAME            : Bamey Ganado
SEMESTER   : 2nd SEMESTER,2023
COURSE        : HUMAN BIOLOGY BL133
 

Interpreting and analyzing diagnostic test results is a critical component of patient assessment in
medical-surgical nursing. Nurses must understand the purpose of each test, the normal reference
ranges, and the potential implications of abnormal findings. Responding to abnormal findings
may involve notifying the healthcare provider, adjusting medication dosages, or implementing
other interventions.

Overall, diagnostic tests and procedures provide valuable information about a patient's health
status and can help guide the development of nursing care plans and interventions. Nurses must
have a thorough understanding of common diagnostic tests and procedures and be able to
interpret and analyze test results to provide safe and effective care.

V. Nursing Diagnosis and Planning

Nursing diagnosis and planning are critical components of patient assessment in medical-surgical
nursing. Nursing diagnoses are clinical judgments about a patient's health status that provide the
basis for developing a nursing care plan. Nursing care plans outline specific goals, interventions,
and outcomes to address the patient's unique health needs.

Nursing diagnoses are based on the information gathered during the health history, physical
examination, and diagnostic tests and procedures. They identify actual or potential health
problems that nurses can address through nursing interventions. Common nursing diagnoses in
medical-surgical nursing may include pain, impaired gas exchange, risk for infection, impaired
mobility, and altered nutrition.

Once nursing diagnoses have been identified, nursing care plans can be developed to address the
patient's specific needs. The nursing care plan outlines specific interventions to address the
patient's health problems and achieve the desired outcomes. Interventions may include
medication administration, patient education, wound care, and monitoring vital signs.

The nursing care plan also includes measurable goals and outcomes that provide a basis for
evaluating the effectiveness of nursing interventions. Goals and outcomes should be specific,
measurable, achievable, relevant, and time-bound (SMART). Evaluating outcomes is critical in
determining the effectiveness of nursing interventions and identifying any needed changes to the
nursing care plan.

Overall, nursing diagnosis and planning are critical components of patient assessment in
medical-surgical nursing. Nursing diagnoses provide a basis for developing nursing care plans
that address the patient's unique health needs, and evaluating outcomes is critical in determining
the effectiveness of nursing interventions.
NAME            : Bamey Ganado
SEMESTER   : 2nd SEMESTER,2023
COURSE        : HUMAN BIOLOGY BL133
 

VI. Implementation of Nursing Care

The implementation of nursing care is a critical component of patient assessment in medical-

surgical nursing. It involves the delivery of nursing interventions outlined in the nursing care
plan to address the patient's unique health needs. Implementation of nursing care requires the
nurse to use critical thinking, clinical judgment, and technical skills to provide safe and effective
care.

Nursing interventions may include medication administration, wound care, patient education,
and monitoring vital signs. The nurse must ensure that interventions are implemented correctly
and in a timely manner to achieve the desired outcomes outlined in the nursing care plan.

In addition to delivering nursing interventions, the nurse must also communicate effectively with
other healthcare team members to ensure that the patient receives comprehensive and
coordinated care. This may include collaborating with physicians, physical therapists, and social
workers to address the patient's unique health needs.

Documentation is also an essential component of implementing nursing care. The nurse must
accurately and thoroughly document all nursing interventions, as well as the patient's response to
those interventions. Documentation provides a record of the care provided, facilitates
communication between healthcare team members, and ensures that the patient's care is well-
documented and easily accessible.

Overall, the implementation of nursing care is a critical component of patient assessment in

medical-surgical nursing. Nurses must use critical thinking, clinical judgment, and technical
skills to deliver safe and effective care, communicate effectively with other healthcare team
members, and document all interventions and patient responses accurately and thoroughly.

VII. Evaluation and Documentation

Evaluation and documentation are critical components of patient assessment in medical-surgical

nursing. Evaluation involves assessing the effectiveness of nursing interventions in achieving the
desired outcomes outlined in the nursing care plan. Documentation provides a record of the care
provided, as well as the patient's response to that care.

Evaluation of nursing interventions involves comparing the patient's current health status to the
desired outcomes outlined in the nursing care plan. The nurse must assess whether the
interventions have been effective in achieving the desired outcomes, and make any necessary
adjustments to the nursing care plan if needed.
NAME            : Bamey Ganado
SEMESTER   : 2nd SEMESTER,2023
COURSE        : HUMAN BIOLOGY BL133
 

Documentation is a critical component of evaluation, as it provides a record of the care provided

and the patient's response to that care. Accurate and thorough documentation is essential to
ensure that the patient's care is well-documented and easily accessible to other healthcare team
members.

Documentation may include nursing notes, progress notes, and other relevant documentation,
such as diagnostic test results and medication administration records. The nurse must ensure that
all documentation is complete, accurate, and timely, and that it follows organizational policies
and procedures.

In addition to documenting the care provided and the patient's response to that care, the nurse
may also need to provide education and support to the patient and their family members. This
may include providing information about the patient's health condition, explaining the purpose of
interventions, and teaching the patient and family members how to manage the patient's health at
home.

Overall, evaluation and documentation are critical components of patient assessment in medical-
surgical nursing. Evaluation involves assessing the effectiveness of nursing interventions in
achieving the desired outcomes, while documentation provides a record of the care provided and
the patient's response to that care. The nurse must ensure that all documentation is complete,
accurate, and timely, and that it follows organizational policies and procedures.

VIII. Conclusion

In conclusion, patient assessment is a critical component of medical-surgical nursing. It involves

obtaining a comprehensive health history, conducting a physical examination, and performing
diagnostic tests and procedures to gather data about the patient's health status. Based on this
information, nursing diagnoses are developed, and nursing care plans are created to address the
patient's unique health needs. Implementation of nursing care requires the delivery of nursing
interventions outlined in the nursing care plan, effective communication with other healthcare
team members, and accurate and thorough documentation. Evaluation involves assessing the
effectiveness of nursing interventions in achieving the desired outcomes, and documentation
provides a record of the care provided and the patient's response to that care. In summary, patient
assessment is an essential component of medical-surgical nursing that requires critical thinking,
clinical judgment, and technical skills to deliver safe and effective care.