The nursing assessment includes gathering information concerning the patient's individual physiological, psychological, sociological, and spiritual needs. It is the first step in the successful evaluation of a patient. Subjective and objective data collection are an integral part of this process. Part of the assessment includes data collection by obtaining vital signs such as temperature, respiratory rate, heart rate, blood pressure, and pain level using an age or condition appropriate pain scale.
The assessment identifies current and future care needs of the patient by allowing the formation of a nursing diagnosis. The nurse recognizes normal and abnormal patient physiology and helps prioritize interventions and care. The function of the initial nursing assessment is to identify the assessment parameters and responsibilities needed to plan and deliver appropriate, individualized care to the patient. Initial Assessment [10] [11] [12].
Which provides the diagnosis most often: history, physical, or diagnostic tests? Pain, or the fifth vital sign, is a crucial component in providing the appropriate care to the patient. Pain assessment may be subjective and difficult to measure. Pain is anything the patient or client states that it is to them. As nurses, you should be aware of the many factors that can influence the patient's pain.
Systematic pain assessment, measurement, and reassessment enhance the ability to keep the patient comfortable. Pain scales that are age appropriate assist in the concise measurement and communication of pain among providers.
Improvement of communication regarding pain assessment and reassessment during admission and discharge processes facilitate pain management, thus enhancing overall function and quality of life in a trickle-down fashion.
According to one performance and improvement outpatient project in , areas for improvement in pain reassessment policies and procedures were identified in a clinic setting. The study concluded compliance rates for the minute time requirement outlined in the clinic policy for pain reassessment were found to be low. Heavy patient load, staff memory rather than documentation, and a lack of standardized procedures in the electronic health record EHR design played a role in low compliance with the reassessment of pain.
Barriers to pain assessment and reassessment are important benchmarks in quality improvement projects. Key performance indicators KPIs to improve pain management goals and overall patient satisfaction, balanced with the challenges of an opioid crisis and oversedation risks, all play a role in future research studies and quality of care projects.
Recognition of indicators of pain and comprehensive knowledge in pain assessment will guide care and pain management protocols. The primary consideration is the health and emotional needs of the patient. Assessment of cognitive function, checking for hallucinations and delusions, evaluating concentration levels, and inquiring into interests and level of activity constitute a mental or emotional health assessment.
Asking about how the client feels and their response to those feelings is part of a psychological assessment. Are they agitated, irritable, speaking in loud vocal tones, demanding, depressed, suicidal, unable to talk, have a flat affect, crying, overwhelmed, or are there any signs of substance abuse? The psychological examination may include perceptions, whether justifiable or not, on the part of the patient or client.
Religion and cultural beliefs are critical areas to consider. Screening for delirium is essential because symptoms are often subtle and easily overlooked, or explained away as fatigue or depression. The cultural competency assessment will identify factors that may impede the implementation of nursing diagnosis and care. Information obtained should include:.
Often the initial history and physical examination lead to the identification of life- or limb-threatening conditions that can be stabilized promptly, ensuring better patient outcomes. The sooner the patient is correctly assessed, the more likely a life-altering condition is recognizable, nursing diagnosis formulated, appropriate intervention or treatment initiated, and stabilizing care rendered. Physiological abnormalities manifested by changes in vital signs and level of consciousness often provide early warning signs that patient condition is deteriorating; thus, requiring prompt intervention to forego an adverse outcome, decreasing morbidity and mortality risk.
In the fast-paced, resource-challenged healthcare environment today, thorough assessment can pose a challenge for the healthcare provider but is essential to safe, quality care. The importance of a head-to-toe assessment, critical thinking skills guided by research, and therapeutic communication are the mainstays of safe practice. Assessment findings that include current vital signs, lab values, changes in condition such as decreased urine output, cardiac rhythm, pain level, and mental status, as well as pertinent medical history with recommendations for care, are communicated to the provider by the nurse.
Communicating in a concise, efficient manner in rapidly changing situations and deteriorating patient conditions can promote quick solutions during difficult circumstances. Healthcare providers communicate and share in the decision-making process. The SBAR model facilitates this communication between members of the healthcare team and bridges the gap between a narrative, descriptive approach and one armed with exact details. This book is distributed under the terms of the Creative Commons Attribution 4.
Turn recording back on. National Center for Biotechnology Information , U. StatPearls [Internet]. Search term. Last Update: August 30, Analysis or diagnosis formulate a nursing diagnosis by using clinical judgment; what is wrong with the patient. Issues of Concern The function of the initial nursing assessment is to identify the assessment parameters and responsibilities needed to plan and deliver appropriate, individualized care to the patient.
Admission history and physical assessment as soon as the patient arrives at the unit or status is changed to an inpatient. Data collected should be entered on the Nursing Admission Assessment Sheet and may vary slightly depending on the facility.
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When skin is pinched it goes to previous state immediately 2 seconds. With fair complexion. With dry skin. Evenly distributed hair.
With short, black and shiny hair. With presence of pediculosis Capitis. Smooth and has intact epidermis With short and clean fingernails and toenails. Convex and with good capillary refill time of 2 seconds.
Rounded, normocephalic and symmetrical, smooth and has uniform consistency. Absence of nodules or masses. Hair evenly distributed with skin intact. Eyebrows are symmetrically aligned and have equal movement. Skin intact with no discharges and no discoloration. Lids close symmetrically and blinks involuntary. Transparent, smooth and shiny upon inspection by the use of a penlight which is held in an oblique angle of the eye and moving the light slowly across the eye.
Has [brown] eyes. Black, equal in size with consensual and direct reaction, pupils equally rounded and reactive to light and accommodation, pupils constrict when looking at near objects, dilates at far objects, converge when object is moved toward the nose at four inches distance and by using penlight.
When looking straight ahead, the client can see objects at the periphery which is done by having the client sit directly facing the nurse at a distance of feet.
Hold penlight in the periphery and ask the client when the moving object is spotted. Patient was able to read the newsprint at a distance of 8 inches. Color of the auricles is same as facial skin, symmetrical, auricle is aligned with the outer canthus of the eye, mobile, firm, non-tender, and pinna recoils after it is being folded.
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