Nursing health Assessment part of nursing process: Assessment, Nursing diagnosis, Planning, Implementation, Evaluation. Nursing health Assessment is the process of collecting, validating, and clustering data. It is the first and most important step in the nursing process. The Nursing assessment phase sets the tone for the rest of the process, and the rest of the process flows from it. If your assessment is off the mark, then the rest of the process will be too. Nursing Assessment identifies your patient’s strengths and limitations and is performed not just once, but continuously throughout the nursing process. After performing your initial assessment, you establish your baseline, identify nursing diagnoses, and develop a plan. Then, as you implement your plan, you also assess your patient’s response. Finally, you assess the effectiveness of your plan of care for your patient
The purpose of Nursing health assessment is to collect data of patient’s health status, to identify deviations from normal, to discover the patient’s strengths and coping resources, to point actual problems, and factors that place the patient at risk for health problems
Data from nursing assessment can be classified as subjective and objective.
Subjective data not measurable. They reflect what the patient is experiencing and include thoughts, beliefs, feelings, sensations, and perceptions. Subjective findings are referred to as symptoms. patients health history is an example of subjective data.
Objective data are overt and measurable. Objective data are referred to as signs. Nursing physical examination and diagnostic studies are examples of objective data. Data sources are either primary or secondary. The patient is a primary data source. Secondary data sources come from anyone or anything aside from the patient, including family members, friends, other healthcare providers, and old medical records. Both primary and secondary data can also be subjective or objective.
Assessment Process, Nursing health Assessment is an ongoing process. Every patient encounter provides you with an opportunity for assessment.
Types of Assessment Nursing Assessments can be comprehensive or focused. A comprehensive assessment is usually the initial assessment. It is very thorough and includes a detailed health history and physical examination:
comprehensive assessment examines the patient’s overall health status.
focused assessment is problem oriented and may be the initial assessment or an ongoing assessment. focused assessment is frequently performed on an ongoing basis to monitor and evaluate the patient’s progress, interventions, and response to treatments. Even when a focused assessment is performed, it is important to look at the entire picture. A problem in one system will affect or be affected by every other system so scan your patient from head to toe and note any changes in other systems. Look for clues or pertinent data that will help you formulate your diagnosis.
Nursing Assessment and Medical Assessment
Medical and nursing assessments should not contradict, each other in promoting the patient’s health and wellness. Often, data obtained through the nursing assessment contribute to the identification of medical problems. By working together in a collaborative relationship, nursing and medicine ensure the best possible care for patients
Health Assessment is not unique to nursing. It is also an integral part of medical practice. The assessment process Could be same for nursing and medical practice, but the outcomes different. The goal of medical practice is to diagnose and treat disease. and The goal of nursing process is to diagnose and treat human responses to actual or potential health problems. Nursing assessment focuses on physiological and psychological responses and the psychosocial, cultural, developmental, and spiritual dimensions. It identifies patients’ responses to health problems as well as their strengths. Optimal level of wellness is the Nursing’s aim.
Methods of Collecting Data
- Physical Assessment