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Nursing assessment

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Dec 17, 2021

Nursing assessment is the gathering of information about a patient‘s physiological, psychological, sociological, and spiritual status by a licensed Registered Nurse. Nursing assessment is the first step in the nursing process. A section of the nursing assessment may be delegated to certified nurses aides. Vitals and EKG’s may be delegated to certified nurses aides or nursing techs. (Nurse Journal, 2017) It differs from a medical diagnosis. In some instances, the nursing assessment is very broad in scope and in other cases it may focus on one body system or mental health. Nursing assessment is used to identify current and future patient care needs. It incorporates the recognition of normal versus abnormal body physiology. Prompt recognition of pertinent changes along with the skill of critical thinking allows the nurse to identify and prioritize appropriate interventions.[1][2] An assessment format may already be in place to be used at specific facilities and in specific circumstances.[3]

. . . Nursing assessment . . .

See also: Nursing process

Before assessment can begin the nurse must establish a professional and therapeutic mode of communication. This develops rapport and lays the foundation of a trusting, non-judgmental relationship. This will also assure that the person will be as comfortable as possible when revealing personal information. A common method of initiating therapeutic communication by the nurse is to have the nurse introduce herself or himself. The interview proceeds to asking the client how they wish to be addressed and the general nature of the topics that will be included in the interview.[4]

The therapeutic communication methods of nursing assessment takes into account developmental stage (toddler vs. the elderly), privacy, distractions, age-related impediments to communication such as sensory deficits and language, place, time, non-verbal cues. Therapeutic communication is also facilitated by avoiding the use of medical jargon and instead using common terms used by the patient.[4]

During the first part of the personal interview, the nurse carries out an analysis of the patient needs.[5] In many cases, the client requires a focused assessment rather than a comprehensive nursing assessment of the entire bodily systems. In the focused assessment, the major complaint is assessed. The nurse may employ the use of acronyms performing the assessment:

  • OLDCART
    • Onset of health concern or complaint
    • Location of pain or other symptoms related to the area of the body involved
    • Duration of health concern or complaint
    • Characteristics
    • Aggravating factors or what makes the concern or complaint worse
    • Relieving factors or what makes the concern or complaint better
    • Treatments or what treatments were tried in the past or ongoing[6]
Auscultatory method aneroid sphygmomanometer with stethoscope

The patient history and interview is considered to be subjective but still of high importance when combined with objective measurements. High quality interviewing strategies include the use of open-ended questions. Open-ended questions are those that cannot be answered with a simple “yes” or “no” response. If the person is unable to respond, then family or caregivers will be given the opportunity to answer the questions.[3]

The typical nursing assessment in the clinical setting will be the collection of data about the following:

  • present complaint and nature of symptoms
  • onset of symptoms
  • severity of symptoms
  • classifying symptoms as acute or chronic
  • health history[7]
  • family history
  • social history
  • current medical and/or nursing management
  • understanding of medical and nursing plans
  • perception of illness[8]

In addition, the nursing assessment may include reviewing the results of laboratory values such as blood work and urine analysis. Medical records of the client assist to determine the baseline measures related to their health.

In some instances, the nursing assessment will not incorporate the typical patient history and interview if prioritization indicates that immediate action is urgent to preserve the airway, breathing and circulation. This is also known as triage and is used in emergency rooms and medical team disaster response situations. The patient history is documented through a personal interview with the client and/or the client’s family. If there is an urgent need for a focused assessment, the most obvious or troubling complaint will be addressed first. This is especially important in the case of extreme pain.

. . . Nursing assessment . . .

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. . . Nursing assessment . . .