This article contains instructions, advice, or how-to content. (January 2012)
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".
This section is in a list format that may be better presented using prose. (January 2009)
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.
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.
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.
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.
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.
A range of instruments has been developed to assist nurses in their assessment role. These include: the index of independence in activities of daily living, the Barthel index, the Crighton Royal behaviour rating scale, the Clifton assessment procedures for the elderly, the general health questionnaire, and the geriatric mental health state schedule.
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".
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