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A nursing assessment is a process where a nurse gathers, sorts and analyzes a patient’s health information using evidence informed tools to learn more about a patient’s overall health, symptoms and concerns. This includes considering the patient’s biological, social, psychological, cultural and spiritual values and beliefs.
- Head-To-Toe Admission Assessment. This is one of the most comprehensive nursing assessments to conduct and is usually done when a patient first arrives on an inpatient nursing unit.
- Routine Head-To-Toe Assessment. In addition to completing a comprehensive head-to-toe assessment when patients are admitted, they are also re-assessed at routine intervals, depending on the unit.
- Focused Nursing Assessments. Focused 🔎 assessments are nursing assessments that target the specific body system where the patient demonstrates a problem, disorder, or concern.
- Emergency Assessments. Patient emergencies happen in all areas of the hospital. They most often occur in the emergency room and the intensive care unit, but they can happen in any unit.
Dec 28, 2023 · Nursing assessment is important because it establishes a baseline understanding of a patient’s condition, enabling accurate diagnosis, personalized care planning, and informed decision-making. It helps detect issues early, supports effective communication among healthcare teams, and guides interventions.
Aug 28, 2023 · The nursing assessment includes gathering information concerning the patient's individual physiological, psychological, sociological, and spiritual needs. It is the first step in the successful evaluation of a patient. Subjective and objective data collection are an integral part of this process.
- Tammy J. Toney-Butler, Wendy J. Unison-Pace
- 2023/08/28
- 2019
- Head
- Ears
- Eyes
- Nose
- Throat
- Neck
- Respiratory
- Cardiac
- Abdomen
- Pulses
Moving hair in sections to look for injuriesObserving the scalp to look for lice, dandruff, or lesionsInspecting the head for masses or tendernessChecking that facial movements are symmetrical by asking patients to move their eyebrows or smileUsing an otoscope to look for discharge or skin discolorationHitting a tuning fork to test for hearing lossInvestigating cerumen (earwax) impaction as a cause of hearing lossAsking patients about any medications they takeVisually inspect the eyes for excessive discharge, redness, or growthsRecord eyesight aids patient uses, including contacts or eyeglassesCheck the pupils for PERRLA — Pupils: Equal, Round, Reactive to Light, and Accommodation (transitioning focus between close and far objects)Using their thumb to palpate one sinus at a time to identify pain or tendernessClosing one nostril at a time to check for normal airflowChecking to make sure that the nose is the same color as the patient’s faceUse a tongue depressor to inspect the cheeks for abnormalities such as lesionsExamine the top and underside of the tongue for discolorationVisually inspect the lips for lesionsCheck the coloration of the lips and gumsPalpating the sides of the neck to check for swollen lymph nodesChecking the neck for tenderness and lumpsInspecting thyroid size and shapeExamining the back of the neck for signs of spinal column injuriesMaking visual assessments of a patient’s respiratory rateAsking patients if they experience shortness of breath or have a coughPlacing their hand to the patient’s back to evaluate symmetrical chest rise.Using the stethoscope to listen for full inspiration and expirationUsing a stethoscope to auscultate the five points of the heart: Erb’s point and the aortic, pulmonic, tricuspid, and mitral valvesPalpating the chest wall, looking for vibratory sensationsListening for normal heart rates and rhythmsAsking questions about any pain in bowel and urination movementsInspecting the abdomen to look at contours and pulsationsLooking for masses or woundsUsing the stethoscope to listen to bowel sounds at all four quadrantsCheck the temporal artery for a pulseFind the apical pulse pointAssess the blood pressure by checking the brachial arteryPalpate the radial, femoral, posterior tibial, and dorsalis pedi pulse pointsAug 26, 2023 · Nursing assessment is a crucial process in the delivery of high-quality healthcare. It involves gathering information about a patient’s physical, psychological, and emotional health status, as well as the social and environmental factors that may impact their health. The nursing assessment process provides a foundation for the development of ...
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Aug 15, 2024 · The nursing assessment is the first step of the nursing process. The other steps are: Diagnosis: Based on the information gathered in the assessment, the registered nurse formulates a diagnosis that not only acknowledges the patient's physical issues but also their ramifications on their psychological, social and spiritual state.
