Nursing assessment

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. The Nursing assessment can not be delegated to unlicensed personnel. 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]

The client interview

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-judgemental 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 elderely), 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:

Patient history and interview

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.

Physical examination

Assessing blood pressure

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.[9]

Focused assessment

Neurovasular assessment

The nurse conducts a neurovascular assessment to determine sensory and muscular function of the arms and legs in addition to peripheral circulation. The focused neurovascular assessment includes the objective observation of pulses, capillary refill, skin color and temperature, and sensation. During the neurovascular assessment the measures between extremities are compared.[1] A neurovascular assessment is an evaluation of the extremities along with sensory, circulation and motor function.[10][11]

Mental status

During the assessment, interactions and functioning are evaluated and documented. Those specific items assessed include:

Pain

Integument

Performing an eye exam by military nurses
assessing the throat of a child

Psychosocial assessment

Abdominal palpation of a boy

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.

Safety

Cultural assessment

The nursing cultural assessment will identify factors that may impede or facilitate the implementation of a nursing diagnosis. Cultural factors have a major impact on the nursing assessment. Some of the information obtained during the interview include:

Assessment tools

Auscultation assessing lung sounds.

A range of instruments and tools have been developed to assist nurses in their assessment role. These include:[17] the index of independence in activities of daily living,[18] the Barthel index,[19] the Crighton Royal behaviour rating scale,[20] the Clifton assessment procedures for the elderly,[21] the general health questionnaire,[22] and the geriatric mental health state schedule.[23]

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"

The use of medical equipment is routinely employed to conduct a nursing assessment. These include, the otoscope, thermometer, stethoscope, penlight, sphygmomanometer, bladder scanner, speculum, and eye charts. Besides the interviewing process, the nursing assessment utilizes certain techniques to collect information such as observation, auscultation, palpation and percussion.

See also

References

  1. 1 2 Schreiber 2016, p. 55.
  2. ↑ Bates, Barbara (1995). A pocket guide to physical examination and history taking. Philadelphia: Lippincott. ISBN 9780397550579.
  3. 1 2 Ackley 2011, p. 4.
  4. 1 2 Henry 2016, p. 127.
  5. ↑ "The Nursing Process". American Nurses Association. 2016. Retrieved 2016-09-05.
  6. ↑ D'Amico 2016, p. 120-21.
  7. ↑ D'Amico 2016, p. 117.
  8. ↑ "Physical Assessment of the Well Woman". University of Manitoba. Archived from the original on 2006-09-28. Retrieved 2006-10-31.
  9. ↑ "Components of a physical assessment". Sweethaven Publishing. Archived from the original on 2006-06-20. Retrieved 2006-10-31.
  10. ↑ Schreiber 2016, p. 55-57.
  11. 1 2 3 4 "Comprehensive Nursing Assessment" (PDF). Department of Mental Health and Hygiene. Maryland.gov. 6 June 2012. Retrieved 9 November 2016.
  12. ↑ Bates 1995, p. 17.
  13. ↑ Bates 1995, p. 21.
  14. ↑ Bates 1995, p. 22.
  15. ↑ Bates 1995, p. 25.
  16. ↑ Townsend 2015, pp. 582-2.
  17. ↑ "Nursing assessment and older people" (PDF). Royal College of Nursing. Retrieved 2006-10-31.
  18. ↑ Katz, S; Stroud M (1963). "Functional assessment in geriatrics: a review of progress and direction". Journal of the American Geriatrics Society. 37: 267–271.
  19. ↑ Mahoney, F; Barthel D (1965). "Functional evaluation: the Barthel index". Maryland State Medical Journal. 14: 61–65. PMID 14258950.
  20. ↑ 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.
  21. ↑ Pattie, A.; Gilleard, C. (1979). Manual of the Clifton assessment procedures for the elderly. Essex: Hodder and Stoughton.
  22. ↑ Goldberg, D (1972). The detection of psychiatric illness by questionnaire: a technique for the identification and assessment of non-psychotic psychiatric illness. Oxford: OUP. ISBN 0-19-712143-8.
  23. ↑ Copeland 1976.

Bibliography

Journals

Further reading and external resources


This article is issued from Wikipedia - version of the 11/30/2016. The text is available under the Creative Commons Attribution/Share Alike but additional terms may apply for the media files.