Nursing assessment

Nursing assessment is the gathering of information about a patient's physiological, psychological, sociological, and spiritual status by a licensed Registered Nurse. Nursing assessment is the first step in the Nursing process. The Nursing assessment can not be delegated to unlicensed personnel. 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 assessment is used to identify current and future patient care needs. It incorporates the recognition of normal versus abnormal body physiology. Prompt recognition of pertinent changes along with the skill of critical thinking allows the nurse to identify and prioritize appropriate interventions. An assessment format may already be in place to be used at specific facilities and in specific circumstances.

Before assessment can begin the nurse must establish a professional and therapeutic mode of communication. This develops rapport and lays the foundation of a trusting, non-judgemental relationship. This will also assure that the person will be as comfortable as possible when revealing personal information. A common method of initiating therapeutic communication by the nurse is to have the nurse introduce herself or himself. The interview proceeds to asking the client how they wish to be addressed and the general nature of the topics that will be included in the interview.

The therapeutic communication methods of nursing assessment takes into account developmental stage (toddler vs. the elderely), privacy, distractions, 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 medical jargon and instead using common terms used by the patient.

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. In the focused assessment, the major complaint is assessed. The nurse may employ the use of acronyms performing the assessment:

The patient history and interview 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.

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