nursing assessment


Also found in: Dictionary, Thesaurus, Legal, Financial, Encyclopedia, Wikipedia.
Related to nursing assessment: Nursing process

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

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
References in periodicals archive ?
RN subjects in the experimental decision making intervention group read a sample patient vignette and completed assessment of care requirements using the nursing assessment decision grid.
She is a registered nurse, a licensed nursing home administrator and a paralegal with a Bachelor of Science in nursing, and holds certifications in Healthcare Risk Management, Case Management, Legal Nurse Consulting and Nursing Assessment. She has dedicated her career to quality improvement of care and services to thousands of patients and residents nationwide.
Information about CAM increases the awareness and importance of including a patient's belief systems, attempted strategies, and his or her internal belief culture into a complete nursing assessment.
Detailed documentation demonstrates adherence to policies and procedures, your nursing assessment and interventions, and what patient education was provided.
I said "yes!", so here it is in their own words: We, the district nurses, are part of a dedicated team of professionals who undertake complex nursing assessment, provide exceptional palliative care and undertake chronic disease management, yet the public's perception of our service provision varies considerably.
Using a combination of local classroom sites (with participants split into teams) and online instruction, the teams focused on issues relevant to nursing assessment, health promotion, and review of current standards, continuing the movement of translating evidence into practice.
"Alterations in Movement: Nursing Assessment and Implications" (Konikow, 1985) in JNN's February 1985 issue demonstrates that perhaps nowhere have changes in drug therapy become more apparent than in the movement disorders field.
The introduction and move to EHRs, however, requires that nursing accept standardized terminology to record its actions, allowing information extracted on nursing assessment, diagnoses, plan and evaluation to be shared across the healthcare environment, within nursing departments, but also with third party payors and other healthcare professionals.
Recalling a partial definition of Nursing Informatics as the integration of clinical nursing skills and technological expertise, I began with an occupational health nursing assessment and a systems analysis.
Zimmerman, PhD, the University of Wisconsin investigator who authored the recently adopted OBRA survey "quality indicators," offered a couple of striking observations in a speech to the American Association of Nursing Assessment Coordinators (AANAC), the fast-growing organization of nurses specializing in PPS reimbursement.

Full browser ?