- A nursing assessment is a procedure in which a nurse collects, sorts, and analyzes a patient’s health data using evidence-based techniques in order to understand more about the patient’s overall health, symptoms, and concerns.
- The patient’s biological, social, psychological, cultural, and spiritual values and beliefs are all taken into account. A nurse then documents and evaluates this information in order to support the patient’s treatment plan and continuing health-related decision-making, which may involve detecting urgent, emergent, or life-threatening illnesses.
- Nursing assessments are essential for patient safety since a lack of them can put patients in danger. In any area of nursing practice, timely and adequate holistic nursing evaluation is a key competence that all nurses should display.
What does a nurse assessment entail?
- During a nursing assessment, the nurse gathers both subjective and objective information to assess the patient as a whole, using evidence-based tools. The following items may be included in a nursing assessment, but are not limited to:
- environmental assessment
- cultural assessment
- physical assessment
- psychological assessment
- safety assessment
- psychosocial assessment
- When reviewing the findings of their evaluations, nurses employ critical thinking to help them make judgments regarding a patient’s care plan. Nurses can prioritize treatments and care delivery by recognizing normal and abnormal patient physiology. Nurses also discuss and collaborate with other members of the healthcare team in order to make informed decisions about patient care.
- Nurses are responsible for reassessing patients on a regular basis to ensure that the care plan continues to satisfy the patients’ needs and to address any changes in the patients’ health. Reassessing patients on a regular basis is critical to ensuring patient safety and improving health outcomes. Failure to do so could put their health in jeopardy.
- Despite the fact that performing assessments is part of a nurse’s basic abilities, it is vital that nurses keep this knowledge and skill up to date. Throughout their nursing careers, nurses can maintain or improve their assessment competency through specialized education or the acquisition of new skills. Every day, all nurses must reflect on their practice to evaluate their learning requirements and actively update their knowledge and abilities to stay competent. Nurses are expected to participate in Quality Assurance and to continue their education and training.
What should a nurse consider when determining an assessment?
- When summarizing the patient’s circumstance, a theory, framework, or evidence-based tool should be employed. To design a patient-centered care plan, nurses should consult with the patient and other members of the health care team.
- Because the patient is the expert of their own life, it is critical to include them in care decisions. The patient’s goals, wishes, and preferences should be identified in the care plan. Patients’ decisions can be influenced by their personal values as well as cultural and religious views. Nurses are aware of and respectful of their patients’ choices.