World Library  
Flag as Inappropriate
Email this Article

Nursing assessment

Article Id: WHEBN0002810347
Reproduction Date:

Title: Nursing assessment  
Author: World Heritage Encyclopedia
Language: English
Subject: Nursing, Nursing diagnosis, Nursing care plan, List of nurses, Assessment
Collection:
Publisher: World Heritage Encyclopedia
Publication
Date:
 

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 carries 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". Now

Components

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: the client's overall health status, the course of the present illness including symptoms, the current management of illness, the client's medical history (including familial medical history), social history and how the client perceives his illness.[1]

Psychological and social examination

The main areas considered in a psychological examination are intellectual health and emotional health. Assessment of cognitive function, checking for hallucinations and delusions, measuring concentration levels, and inquiring into the client's hobbies and interests constitute an intellectual health assessment. Emotional health is assessed by observing and inquiring about how the client feels and what he does in response to these feelings. The psychological examination may also include the client's perceptions (why they think they are being assessed or have been referred, what they hope to gain from the meeting). Religion and beliefs are also important areas to consider. The need for a physical health assessment is always included in any psychological examination to rule out structural damage or anomalies.

Physical examination

A nursing assessment includes a physical examination: the observation or measurement of signs, 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 Inspection, 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

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] the index of independence in activities of daily living,[5] the Barthel index,[6] the Crighton Royal behaviour rating scale,[7] the Clifton assessment procedures for the elderly,[8] the general health questionnaire,[9] and the geriatric mental health state schedule.[10]

Other assessment tools may focus on a specific aspect of the patient's care. For example, the Waterlow score and the Braden scale deals with a patient's risk of developing a Pressure ulcer (decubitus ulcer), the Glasgow Coma Scale measures the conscious state of a person, and various pain scales exist to assess the "fifth vital sign".

See also

References

  1. ^ "Physical Assessment of the Well Woman". University of Manitoba. Archived from the original on 2006-09-28. Retrieved 2006-10-31. 
  2. ^ "Signs and Symptoms: The Basics of Assessment". About. Retrieved 2006-10-31. 
  3. ^ "Components of a physical assessment". Sweethaven Publishing. Archived from the original on 2006-06-20. Retrieved 2006-10-31. 
  4. ^ "Nursing assessment and older people". Royal College of Nursing. Retrieved 2006-10-31. 
  5. ^ Katz, S; Stroud M (1963). "Functional assessment in geriatrics: a review of progress and direction". Journal of the American Geriatrics Society 37: 267–271. 
  6. ^ Mahoney, F; Barthel D (1965). "Functional evaluation: the Barthel index". Maryland State Medical Journal 14: 61–65.  
  7. ^ Wilkin, D; Jolley D (1979). Behavioural problems among older people in geriatric wards, psychogeriatric wards and residential homes 1976-1978. University Hospital of South Manchester. 
  8. ^ Pattie, A; Gilleard C (1979). Manual of the Clifton assessment procedures for the elderly. Essex: Hodder and Stoughton. 
  9. ^ Goldberg, D (1972). The detection of psychiatric illness by questionnaire: a technique for the identification and assessment of non-psychotic psychiatric illness. Oxford: OUP.  
  10. ^ Copeland, J; Kelleher M. & Keller J (1976). "A semistructured clinical interview for the assessment of diagnosis and mental state in the elderly: the geriatric mental state schedule – 1 development and reliability". Psychological Medicine 6 (3): 439–449.  

Bibliography

This article was sourced from Creative Commons Attribution-ShareAlike License; additional terms may apply. World Heritage Encyclopedia content is assembled from numerous content providers, Open Access Publishing, and in compliance with The Fair Access to Science and Technology Research Act (FASTR), Wikimedia Foundation, Inc., Public Library of Science, The Encyclopedia of Life, Open Book Publishers (OBP), PubMed, U.S. National Library of Medicine, National Center for Biotechnology Information, U.S. National Library of Medicine, National Institutes of Health (NIH), U.S. Department of Health & Human Services, and USA.gov, which sources content from all federal, state, local, tribal, and territorial government publication portals (.gov, .mil, .edu). Funding for USA.gov and content contributors is made possible from the U.S. Congress, E-Government Act of 2002.
 
Crowd sourced content that is contributed to World Heritage Encyclopedia is peer reviewed and edited by our editorial staff to ensure quality scholarly research articles.
 
By using this site, you agree to the Terms of Use and Privacy Policy. World Heritage Encyclopedia™ is a registered trademark of the World Public Library Association, a non-profit organization.
 



Copyright © World Library Foundation. All rights reserved. eBooks from World Library are sponsored by the World Library Foundation,
a 501c(4) Member's Support Non-Profit Organization, and is NOT affiliated with any governmental agency or department.