Nursing assessment is the gathering of information about a patient's physiological and psychological status by a licensed Registered Nurse. Nursing assessment is the first step in the nursing process. A section of the nursing assessment may be delegated to certified nurses aides. Vitals and EKG's may be delegated to certified nurses aides or nursing techs. (Nurse Journal, 2017) 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 assessments are used to identify current and future patient care needs. They incorporate the recognition of normal versus abnormal body physiology. Prompt recognition of pertinent changes along with the critical thinking allows the nurse to identify and prioritize appropriate interventions. An assessment format may already be in place at certain facilities and during specific circumstances.
The admission When a client is admitted to a facility or institution there are crucial pieces of information that must be gathered in preparation of providing good care and education. The information gathered includes the following:
name, date, time, and sources of identification chief complaint and pain current status (vital signs, mental status, nutritional status) medical history valuables allergies rights and responsibilities risks any pertinent information that could be used by the other members of a health care team
The client interview
The purpose of an interview is to collect subjective data from the client. Subjective data refers to what the patient says is being experienced. Nurses also collect objective data. In the interview, nurses gather some degree of data by observing things like posture, conversation skills, and their overall appearance and mood. Prior to assessment, the nurse establishes a professional and therapeutic mode of communication in order to develop rapport and build a trusting, non-judgmental relationship. This foundation encourages the client to share personal information with greater comfort. Therapeutic communication is typically initiated by the nurse introducing themselves, inquiring how the client prefers to be addressed, and outlining the general nature of the topics to be covered. This exchange also provides an opportunity for the nurse to assess the patient's own perception of their health. Communication within the interview encompasses both sending and receiving information, each occurring through verbal and nonverbal channels. Verbal communication consists of the explicit spoken content exchanged between parties. Nonverbal communication, including facial expressions, eye contact, body language, hand gestures, and use of personal space, is considered equally significant, as it often conveys meaning beyond conscious awareness and requires considerable self-regulation. The types of questions employed during an interview are also important. Closed-ended questions elicit brief, constrained responses such as "yes," "no," or a selection from nurse-provided options, which limits the scope of the client's reply. Open-ended questions, by contrast, allow the client to respond freely and at length, facilitating fuller, more comprehensive expression and a more complete clinical picture. The therapeutic communication methods of the nursing assessment take into account developmental stage (toddler vs. elderly), privacy, distractions, and 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 the following:
medical jargon: adjust vocabulary to where the client can clearly understand what is being said, use common language providing false reassurance giving unwanted advice to the client being authoritative: each person's role in the interview is of equal importance using avoidance language like euphemisms instead of being blunt and direct distancing: don't refer to things like a client's anatomy as “the”, instead use “your” talking too much: let the client do the talking, it allows for optimum sharing of information interrupting the client using biased questions: don't imply that one answer is better than the other using “why” questions: this makes the client have to justify instead of just sharing the information During the first part of the personal interview, the nurse carries out an analysis of the patient needs. In many cases, the client requires a focused assessment rather than a comprehensive nursing assessment of the entire bodily systems, although a complete assessment may be necessary. In the focused assessment, the major complaint is assessed. The nurse may employ the use of acronyms performing the assessment:
OLDCART Onset of health concern or complaint Location of pain or other symptoms related to the area of the body involved Duration of health concern or complaint Characteristics Aggravating factors or what makes the concern or complaint worse Relieving factors or what makes the concern or complaint better Treatments or what treatments were tried in the past or ongoing
Complete health history
The complete health history 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. The typical nursing assessment in the clinical setting will be the collection of data about the following topics included in a health history
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