Nursing assessment

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Assistant Editor-In-Chief: Michelle Lew

## Contents

* 1 Overview
* 2 Stage one of the nursing process
* 3 Components of a nursing assessment
* 3.1 Nursing history
* 3.2 Psychological and social examination
* 3.3 Physical examination
* 4 Documentation of the assessment
* 4.1 Assessment tools
* 5 See also
* 6 References
* 7 Bibliography
* 8 External links

## Overview

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Nursing assessment is the gathering of information about a patient's physiological, psychological, sociological, and spiritual status.

## Stage one of the nursing process

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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 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

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### Nursing history

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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:[1]

* 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

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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

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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 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 of the assessment

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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

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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]
* 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 deals with a patient's risk of developing a Bedsore (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

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* Assessment

## References

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1. ↑ "Physical Assessment of the Well Woman". University of Manitoba. 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. Retrieved 2006-10-31.
4. ↑ "Nursing assessment and older people" (PDF). Royal College of Nursing. Retrieved 2006-10-31.
5. ↑ Katz, S (1963). "Functional assessment in geriatrics: a review of progress and direction". Journal of the American Geriatrics Society. 37: 267–271. Unknown parameter `|coauthors=` ignored (help); line feed character in `|title=` at position 25 (help); line feed character in `|journal=` at position 11 (help)
6. ↑ Mahoney, F (1965). "Functional evaluation: the Barthel index". Maryland State Medical Journal. 14: 61–65. Unknown parameter `|coauthors=` ignored (help); line feed character in `|title=` at position 23 (help)
7. ↑ Wilkin, D (1979). Behavioural problems among older people in geriatric wards, psychogeriatric wards and residential homes 1976-1978. University Hospital of South Manchester. Unknown parameter `|coauthors=` ignored (help)
8. ↑ Pattie, A (1979). Manual of the Clifton assessment procedures for the elderly. Essex: Hodder and Stoughton. Unknown parameter `|coauthors=` ignored (help); line feed character in `|publisher=` at position 11 (help)
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. ISBN 0-19-712143-8.
10. ↑ Copeland, 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: 439–449. Unknown parameter `|coauthors=` ignored (help); line feed character in `|title=` at position 17 (help)

## Bibliography

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* Harkreader, Helen (2003). Fundamentals of Nursing: Caring and Clinical Judgement. W B Saunders Co. ISBN 0-7216-0060-3. Unknown parameter `|coauthors=` ignored (help)

## External links

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* Example of an admission nursing assessment form (PDF file)

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