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Nursing Assessment




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

  • health status

  • course of present illness including symptoms

  • current management of illness

  • past medical history including family's medical history

  • social history

  • perception of illness



Psychological and social examination


The psychological examination may include;
  • Client’s perception (why they think they have been referred/are being assessed; what they hope to gain from the meeting)

  • Emotional health (mental health state, coping styles etc)

  • Social health (accommodation, finances, relationships, Genogram , employment status, ethnic back ground, support networks etc)

  • Physical health (general health, illnesses, previous history, appetite, weight, sleep pattern, diurinal variations, alcohol, tobacco, street drugs; list any prescribed medication with comments on effectiveness)

  • Spiritual health (is religion important? If so, in what way? What/who provides a sense of purpose?)

  • Intellectual health (cognitive functioning, hallucinations, delusions, concentration, interests, hobbies etc)



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