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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.
Aug 28, 2023 · The initial nursing assessment, the first step in the five steps of the nursing process, involves the systematic and continuous collection of data; sorting, analyzing, and organizing that data; and the documentation and communication of the data collected. Critical thinking skills applied during the nursing process provide a decision-making framework to develop and guide a plan of care for the ...
- Tammy J. Toney-Butler, Wendy J. Unison-Pace
- 2023/08/28
- 2019
Dec 28, 2023 · The primary purpose of nursing assessment is to establish a baseline database that reflects the patient’s perceived needs, health problems, and their corresponding responses. This foundational knowledge serves as a baseline for developing individualized care plans, making well-informed clinical judgments, and facilitating effective communication among members of the healthcare team.
Aug 26, 2023 · Types of Nursing Assessment. There are many different types of nursing assessment, depending on the patient’s needs and the setting in which the assessment is being conducted. Some common types of nursing assessment include: Initial Assessment. Conducted shortly after admission, it establishes baseline data for future comparisons.
- Overview
- What is a nursing assessment?
- Why are nursing assessments important?
- 4 types of nursing assessments:
- Tips on how to conduct a successful nursing assessment
Knowing the four types of nursing assessments is an important part of a nurse's medical training. Regardless of the type of medical institution you work for, being familiar with each type of nursing assessment can have a direct impact on your efficiency. Nursing assessments are important medical procedures, but they require knowledge and practice. ...
A nursing assessment is a process of gathering relevant patient information by a registered nurse. The information can describe the patient's physical, psychological, sociological and spiritual situation and is usually the first step in the nursing process. The process consists of collecting the data and applying medical and critical thinking skills to create a care plan for the respective patient, based on their exact needs.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.
•Planning: The medical team develops a care plan that includes the objectives for the respective patient's treatment and recovery, the potential outcomes of the treatment and the interventions needed for the treatment to succeed
•Implementation: Actually performing all the tasks decided in the planning phase
•Evaluation: An analysis of how successful the intervention was and an adjustment on the initial care plan, when needed
Related: 52 Types of Nurses
Nursing assessments are a major part of a registered nurse's role and the data gathered at this stage can significantly affect a patient's health outcome. Aside from evaluating the exact condition that prompted the patient to seek medical care, a thorough nursing assessment can also identify any underlying conditions that the patient did not know a...
1. Initial assessment
Also called a triage, the initial assessment's purpose is to determine the origin and nature of the problem and to use that information to prepare for the next assessment stages. Due to the fact that the rest of the medical process relies on the accuracy of this initial assessment, it is the most thorough phase of the entire process.It usually consists of getting the patient's medical history and performing a physical exam on them or, in the case of patients with mental issues, performing a psychological assessment. Depending on the patient's condition, the initial assessment may also include recording the patient's vital signs and looking for subtle symptoms that may be signs of an underlying condition.Related: What Is a Triage Nurse?
2. Focused assessment
After the initial assessment, the medical issue is fully exposed and treated in the focused assessment phase. Given the fact that a patient's condition may rapidly change, especially in an emergency situation, their vital signs are constantly monitored throughout all four assessments. The focused assessment also involves relieving the patient from pain and stabilizing their condition, when needed. Also, depending on the exact nature of the issue, a long-term treatment plan that aims to resolve the root cause is implemented during this phase.
3. Time-lapsed assessment
After the medical condition is properly diagnosed and a treatment plan is implemented, the time-lapsed assessment is conducted to evaluate how the patient reacts to the agreed treatment plan and how their condition is evolving. Depending on the issue, a time-lapsed assessment can last from a few hours to a few months. Throughout this time, the patient is constantly evaluated and their condition is compared to previously recorded parameters to see if the treatment is effective.Related: Nursing Clinicals FAQ and Tips
Consider these tips on how to correctly and efficiently perform an assessment:
•Build a personal relationship with the patient. Although time is usually very limited, you should try to personally relate with the patient, as this can establish a relationship based on trust and respect that can make the next steps easier for both the patient and the medical team.
•Collect the proper documentation. Begin by getting the patient's name, age, medical record number, main complaint, probable diagnosis and past medical history.
•Assess the pain. By using a pain scale, you can ask the patient to describe the severity of the pain they are experiencing.
•Check for allergies. Many severe medical symptoms are actually caused by allergies, so before considering any medical treatment you should check if the patient has any known adverse reactions to various foods, medications or environmental factors.
•Check what medications the patient is taking. Any subsequent treatment greatly depends on the medications the patient currently takes and their exact dosage.
A pain assessment is an important part of the initial assessment, but it's also a subjective experience and so the nurse should use their experience, in combination with pain scales, to determine how serious the problem is. Some of the signs of serious pain include: Loud moaning and groaning. Restlessness.
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What is an initial nursing assessment?
What is a nursing assessment?
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Why is a nursing assessment important?
What does a registered nurse do during an initial assessment?
1. Interviewing the Patient. The cornerstone of the assessment, this phase allows nurses to gather information about the patient’s medical history, current symptoms, and concerns. 2. Performing a Physical Examination. A comprehensive examination involving a head-to-toe evaluation of the patient’s body. 3.
