In nursing assessment, a licensed Registered Nurse gathers information about a patient’s physiological, psychological, sociological, and spiritual state. The first step in the nursing procedure is to manage a nursing assessment. Certified nurses aides may be committed to a portion of the nursing assessment.
In comparison to what is standard/norm, it is the systematic and continual gathering, validation, and sharing of client data.
The client’s perceived needs, health problems, related experiences, health practices, values, and lifestyles are all included.
Purpose
To create a database that contains all of the client’s information.
- health history of nurses
- physical examination
- laboratory and diagnostic test findings, as well as the physician’s history and physical examination material gathered from other health professionals
There are four different types of nursing assessments
1. Initial Assessment
The goal of the initial assessment, often known as triage, is to discover the source and nature of the problem and use that information to prepare for the subsequent assessment stages. It is the most thorough part of the entire process because the rest of the medical process is dependent on the accuracy of this initial assessment.
It usually involves taking the patient’s medical history and performing a physical examination or, in the case of mental health patients, a psychiatric evaluation. Depending on the patient’s health, the initial examination may also include taking vital signs and looking for mild symptoms that could signal an underlying disease.
2. Focused Assessment
In the focused assessment phase, the medical condition is thoroughly exposed and treated after the initial evaluation. Because a patient’s health might change quickly, especially in an emergency, vital signs are continuously checked throughout all four assessments. When necessary, the focused assessment also includes reducing the patient’s pain and stabilizing their condition. Depending on the nature of the problem, this phase may also include the implementation of a long-term treatment plan aimed at resolving the root cause.
3. Emergency Assessment
During emergency operations, an emergency evaluation is performed to check the patient’s airway, breathing, and circulation, as well as the actual source of the problem. Emergency evaluations can occur outside of traditional healthcare settings, and the registered nurse must ensure that no other individuals are harmed as a result of the emergency rescue procedure. If the emergency assessment goes well and the patient’s vital signs are stable, a targeted assessment is usually the following step.
4. Time-lapsed Assessment
After a medical issue has been correctly diagnosed and a treatment plan has been executed, a time-lapsed evaluation is performed to see how the patient responds to the treatment plan and how their condition is progressing. A time-lapsed examination might run anything from a few hours to several months, depending on the topic. During this time, the patient’s status is regularly monitored and compared to previously recorded characteristics to assess if the treatment is working.
Collection Data
- Information about the client is gathered.
- physical, psychological, emotional, socio-cultural, and spiritual elements that may have an impact on a client’s health
- contains the client’s past medical history (allergies, past surgeries, chronic diseases, use of folk healing methods)
- includes the client’s current and past issues (pain, nausea, sleep pattern, religious practices, meds or treatment the client is taking now)
Types of Data
Subjective data
- Information from the client’s point of view or as stated by the person experiencing it is referred to as Symptom/Covert data.
- Subjective data includes information provided by family members, significant others, and other health experts.
- Pain, dizziness, and ringing in the ears (Tinnitus) are examples of symptoms.
Objective data
- Sign/Overt data is another term for this type of information.
- Those that can be observed, measured, or tested using a commonly acknowledged standard or norm.
- Pallor, diaphoresis, blood pressure of 150/100, skin coloring yellow
Methods of Data Collection
Interview
A planned, meaningful talk with the client to obtain information, identify problems, assess change, teach, or provide support or counseling.
It’s utilized while a client’s nursing history is being taken.
Observation
Use the five senses and devices to collect data.
Examination
Systematic data collecting to detect health issues using units of measurement, physical examination procedures (IPPA), and laboratory results interpretation.
- Cephalocaudal approach – head-to-toe assessment
- Examine all of the body’s systems using the body system approach.
- Review of System approach – examine the only particular area that has been impacted
Source of data
Primary source
Using an interview and a physical examination, data was directly acquired from the client.
Secondary source
Data was acquired from the client’s family, significant others, medical records/charts, other members of the health team, and related care literature/journals.
Obtain a Nursing Health History during the Assessment Phase a systematic interview aimed to collect particular data and create a detailed health record for a client.
A Nursing Health History’s Components
- Name, residence, age, sex, marital status, occupation, and religion are all examples of biographical information.
- The primary reason for the client’s visit/chief complaint is to seek counsel or hospitalization.
- The usual health status, chronological chronology, family history, and disability assessment are all part of the current illness’s history.
- All previous vaccines and disease episodes are included in the past health history.
- Family History exposes elements that increase the risk of various diseases (Diabetes, hypertension, cancer, mental illness).
- Review of systems a thorough examination of all health issues in terms of body systems.
- Lifestyle Personal. routines, diets, sleep or rest patterns, everyday activities, recreation, or hobbies are all examples.
- Social data. Family ties, ethnic and educational backgrounds, economic status, and house and neighborhood environment are all factors to consider.
- Psychological data information about the mental state of the client
- The pattern of health care. It encompasses all healthcare resources, such as hospitals, clinics, healthcare centers, and primary-care physicians.
Validation of Data
The act of “double-checking” or “verifying” facts to ensure accuracy and completeness.
Purposes of data validation
- Ensure that all data is collected.
- Ensure that objective and subjective data concur; collect additional data that may have been ignored, and distinguish between cues and inferences.
Organization of Data
Uses a written or digital format for methodically organizing assessment data.
- Maslow’s basic needs
- Model of the Human Body
- Gordon’s Patterns of Functional Health
Gordon’s Patterns of Functional Health
- The pattern of health perception and management.
- The pattern of nutrition and metabolism
- Pattern of elimination
- Pattern of activity-exercise
- Sleep-rest pattern
- The pattern of cognition and perception
- The pattern of self-perception and self-concept
- Pattern of role-relationships
- Patterns of sexuality and reproduction
- The pattern of coping and stress tolerance
- Pattern of value-belief
Analyze Data
Identify relevant indications by comparing data to industry standards. The term “standard” or “norm” refers to measures, models, and patterns that are widely accepted.
Normal vital signs, weight and height, laboratory/diagnostic readings, and growth and development pattern, for example.
Data should be communicated, recorded, and documented.
- The nurse keeps track of all information gathered concerning the client’s health.
- Data is documented in a true manner, not how the nurse interprets it.
- Record subjective data in the client’s own terms; restating what the client says in different words may modify its original meaning.