Nursing assessment

Nursing assessment is the gathering of information about a patient's physiological, psychological, sosciological 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 theory 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:
• 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 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 musculosceletal systems.

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:
• the index of independence in activity daily living
• the Barthel index
• the Crighton Royal behaviour rating scale
• the Clifton assessment procedures for the elderly
• the general health questionnaire
• the geriatric mental health state schedule

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