nursing assessment

nursing assessment,

an identification by a nurse of the needs, preferences, and abilities of a patient. Assessment includes an interview with and observation of a patient by the nurse and considers the symptoms and signs of the condition, the patient's verbal and nonverbal communication, the patient's medical and social history, and any other information available. Among the physical aspects assessed are vital signs, skin color and condition, motor and sensory nerve function, nutrition, rest, sleep, activity, elimination, and consciousness. Among the social and emotional factors included in assessment are religion, occupation, attitude toward hospital and health care, mood, emotional tone, and family ties and responsibilities. Assessment is extremely important because it provides the scientific basis for a complete nursing care plan.

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assessment [ah-ses´ment]

an appraisal or evaluation.

fetal assessment see fetal assessment.

focused assessment a highly specific assessment performed on patients in the emergency department, focusing on the system or systems involved in the patient's problem.

functional assessment an objective review of an individual's mobility, transfer skills, and activities of daily living, including self care, sphincter control, mobility, locomotion, and communication. It is used to establish a baseline, to predict rehabilitation outcomes, to evaluate therapeutic interventions, and for standardizing communication for research purposes.

lethality assessment a systematic method of assessing a patient's suicide potential.

neurologic assessment see neurologic assessment.

nursing assessment see nursing assessment.

primary assessment a rapid, initial examination of a patient to recognize and manage all immediate life-threatening conditions. Called also primary survey.

secondary assessment a continuation of the primary assessment, where the medical professional obtains vital signs, reassesses changes in the patient's condition, and performs appropriate physical examinations.