nursing assessment

(redirected from Nursing asessment)

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.

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.

nursing assessment

The systematic collection of all data and information relevant to the care of patients, their problems, and needs. The initial step of the assessment consists of obtaining a careful and complete history from the patient. If this cannot be done because the mental or physical condition of the patient makes communication impossible, the nursing history is obtained from those who have information about the patient and the reason(s) for his or her need of medical and nursing care. Obtaining an accurate and comprehensive history requires skill in communicating with individuals who are ill, including those who are reluctant or unable to share important life experiences and medical data. The skilled nurse will be able to obtain the essential information despite resistance. Next in the assessment is the physical examination of the patient in order to determine how the disease has altered physical and mental status. To do this requires that the nurse be capable of performing visual and tactile inspection, palpation, percussion, and auscultation and have knowledge of what represents deviation from the norm and how disease and trauma alter the physical and mental condition of a patient. After these two steps have been completed, the nurse will be able to establish a nursing diagnosis.
See: evaluation; nursing process
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