Nursing assessment

Physical Assessment EducationPURPOSE: is the gathering of information about a patient's physiological, psychological, sociological, and spiritual status.   I. The nursing process   a. Assessment is the first stage of the nursing process in which the nurse should carry out a complete and holistic nursing assessment of every patient's needs, regardless of the reason for the encounter. Usually, an assessment framework, based on a nursing model is used.     b. The purpose of this stage is to identify the patient's nursing problems. These problems are expressed as either actual or potential. For example, a patient who has been rendered immobile by a road traffic accident may be assessed as having the "potential for impaired skin integrity related to immobility".II.  Components of a nursing assessment    a. Nursing history       1.Taking a nursing history prior to the physical examination allows a nurse to establish a rapport with the patient and family.  Elements of the history include:         *health status         *course of present illness including  symptoms         *current management of illness         *past medical history including family's medical history         *social history         *perception of illness    b. Psychological and social examination       1. The psychological examination may include:          * Client’s perception (why they think they have been referred/are being assessed;                 what they hope to gain from the meeting)          * Emotional health (mental health state, coping styles etc)          * Social health (accommodation, finances, relationships, employment status,                    ethnic back ground, support networks etc)          * Physical health (general health, illnesses, previous history, appetite, weight,                sleep pattern, diurinal variations, alcohol, tobacco, street drugs; list any              prescribed medication with comments on effectiveness)          * Spiritual health (is religion important? If so, in what way? What/who provides a                sense of purpose?)          * Intellectual health (cognitive functioning, hallucinations, delusions,                  concentration, interests, hobbies etc)III. Physical examination     a. A nursing assessment includes a physical examination: the observation or measurement          of Medical signs, which can be observed or measured, or symptoms which can be felt             by the patient.         1. The Basics of Assessment            *The techniques used may include Inspection, Palpation, Auscultation and Percussion             in addition to the vital signs and further examination of the body systems such              as the cardiovascular and musculoskeletal systems.IV.  Documentation of the assessment      a. The assessment is documented in the patient's [[medical record or nursing records,             which can be accessed by all members of the healthcare team.V.   Assessment tools     a. A range of instruments has been developed to assist nurses in their assessment role.         These include:        * the index of independence in activities of daily living          * functional assessment in geriatrics: a review of progress and direction         * the Barthel index         * the Crighton Royal behavior rating scale: problems among older people in geriatric             wards, psychogeriatric wards and residential homes         * the Clifton assessment procedures for the elderly        * the general health questionnaire         * the detection of psychiatric illness by questionnaire: a technique for the               identification and assessment of non-psychotic psychiatric illness        * the geriatric mental health state schedule: A semistructured clinical interview           for the assessment of diagnosis and mental state in the elderly.      b. Other assessment tools may focus on a specific aspect of the patient's care. For            example, the Waterlow score deals with a patient's risk of developing decubitus           ulcers, the Glasgow Coma Scale measures the conscious state of a person, and various           pain scales exist to assess the "fifth vital sign".

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