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What is a nursing assessment?
Nursing assessment is the gathering of information about a patient’s physiological, sociological, and spiritual status by a registered nurse. It is the first step of the nursing process. Moreover, it is a key component of nursing practice required for planning and provision of patient and family-centered care.
A nurse uses nursing assessment to identify the patient’s current and future needs. A nurse conducts a comprehensive and systematic nursing assessment. She also plans nursing care with a consultation with the involved individuals and responds effectively to rapidly changing situations. Critical thinking and prompt recognition of pertinent changes allow the nurse to identify and prioritize appropriate interventions. A nursing assessment format may be designed for use by special faculties or on special circumstances.
Types of nursing assessment.
- Admission assessment – This is a comprehensive nursing assessment consisting of patient history, general appearance, physical examination, and other vital signs.
- Focused assessment – This is a detailed nursing assessment of specific body systems relating to the current concerns of the patient. It may include one or more body systems.
- Shift assessment – This is a concise nursing assessment that is completed at the beginning of each shift or when the patient’s condition changes at any other time.
Purpose of health assessment.
The purpose of health assessment is to get a general understanding of the state of your health across your mental, physical, psychological, and sexual wellbeing. Health assessments enable you to take a proactive stance towards your health and screen for certain diseases.
Approach to physical assessment.
- Consider the age and development of the child.
- Implement behavior that shows respect to the child’s age, gender, and other personal preferences.
- Use language which is consistent with the child’s needs.
- Start by building rapport between child and family. Do this by introducing yourself and using play techniques effective on the child.
- First, gather as much information by observation.
- Use systematic approach but remain flexible to accommodate child’s behavior.
- Examine least intrusive areas first and then sensitive assessment areas last.
- Encourage the child and family to voice questions in case of any concerns.
- Clinical assessments should be conducted when the patient is relaxed and compliant unless in emergency situations.
- If any serious concerns arise, the nurse should report to the medical team.
Admission assessment should be completed by the nurse within 24 hours of the patient’s admission. All information collected from the patient should be protected from breach.
This is the assessment of the patient’s overall physical, emotional, and behavioral state. A nurse conducts this on admission and continues throughout the patient’s admission period.
When carrying out this assessment, the nurse observes these considerations:
- For all patients.
- Looks well or unwell.
- Pale or flushed.
- Lethargic or active.
- Agitated or calm.
- Compliant or combative.
- Posture or movement.
- Neonate and infants.
- Parent infant interaction.
- Body symmetry and movement.
- The positioning of facial features.
- Strong cry.
- Young child.
- Child parent interaction.
- Mood and affect.
- Motor skills.
- Developmental milestones.
- Appropriate speech.
- Mood and affect.
These are the baseline observations that a nurse records and documents on the patient’s observation flowsheet. These are some of the vital signs a nurse observes:
- Respiratory rate.
- Heart rate.
- Blood pressure.
- Oxygen saturation.
Some additional measurements which may be considered for admission assessment are:
- Head circumference.
- Blood sugar level.
A well-planned and designed physical assessment enables the nurse to obtain a complete assessment of the patient.
Techniques used to gather information.
This refers to a detailed nursing assessment of specific body systems relating to the presenting problem or other current concerns required. The nursing staff utilizes clinical judgment to determine which elements of a focused assessment are pertinent for their patient. Focused nursing assessment may involve one or more body systems.
This is a nursing assessment performed at the beginning of every shift to every patient. The information collected from performing a shift assessment is used to develop an effective and efficient care plan for the patient. After first documentation of the shift assessment results in the care plan, subsequent assessment results are recorded in the progress notes. Information collected during assessments include:
- Observation of vital signs.