| Nursing Assessment |
Article Index for Nursing |
Website Links For Nursing |
Information AboutNursing Assessment |
| CATEGORIES ABOUT NURSING ASSESSMENT | |
| nursing | |
| assessment, nursing | |
|
Nursing assessment is the gathering of information about a patient's Physiological , Psychological , Sociological , and Spiritual status. STAGE ONE OF THE NURSING PROCESS Assessment is the first stage of the Nursing Process in which the Nurse should carry out a complete and Holistic nursing assessment of every patient's needs, regardless of the reason for the encounter. Usually, an assessment framework, based on a Nursing Model is used. The purpose of this stage is to identify the patient's nursing Problems . These problems are expressed as either actual or potential. For example, a patient who has been rendered immobile by a road traffic accident may be assessed as having the "potential for impaired skin integrity related to immobility". COMPONENTS OF A NURSING ASSESSMENT Nursing history Taking a nursing history prior to the physical examination allows a nurse to establish a rapport with the patient and family. Elements of the history include:1
Psychological and social examination The psychological examination may include;
Physical examination A nursing assessment includes a , which can be observed or measured, or Symptoms such as Nausea or Vertigo , which can be felt by the patient.2 The techniques used may include Palpation , Auscultation and Percussion in addition to the "vital signs" of Temperature , Blood Pressure , Pulse and Respiratory Rate , and further examination of the body systems such as the Cardiovascular or Musculoskeletal systems.3 DOCUMENTATION OF THE ASSESSMENT The assessment is documented in the patient's Medical or Nursing Records , which may be on paper or as part of the Electronic Medical Record which can be accessed by all members of the healthcare team. Assessment tools A range of instruments has been developed to assist nurses in their assessment role. These include:4 |
|
|