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Why The Initial Assessment Is Important In Nursing
The initial nursing assessment is an essential part of the patient care process. It is used by nurses to gather information about an individual before using that data to prepare a care plan and ensure the patient's needs are met.
What is an Initial Nursing Assessment?
A registered nurse uses a nursing assessment to gather information about the patient's physical, emotional, sociological, and mental health needs. It's often the first step in the nursing process and it's also one of the most important.
Once the nursing assessment has been conducted, the nurse can move on to the next steps, which include:
- Diagnosis : The information provided in the nursing assessment is used to make a diagnosis.
- Care Plan: A care plan is developed with consideration for the patient's needs and care objectives.
- Implementation : The tasks outlined in the care plan are implemented and steps are taken to assist the patient with their issue.
- Evaluation : An evaluation is conducted to determine whether the care plan was successful or not and whether any changes are needed.
Each of these steps is just as important as the last, but everything begins with the patient assessment.
What is the Purpose of an Assessment in the Nursing Process?
A patient assessment tells the registered nurse what they need to know about the patient, allowing them to properly prepare and implement a care plan.
If conducted appropriately and expertly, a nursing assessment can greatly improve the patient's health outcome. It can pick up on issues that the patient may have overlooked and ensure they are dealt with promptly and professionally.
What Are the Types of Nursing Assessments?
There are four main types of nursing assessment:
The Initial Assessment
An initial assessment is also known as triage. Its purpose is to determine what the issue is and to prepare for the next steps.
It's typically a lengthy process that covers many facets, including all of the following:
The patient's medical history is a huge part of the assessment process and will provide the nurse with most of the information they need.
Nurses typically use a tool known as PQRST, which stands for:
- Provoke —what provokes the symptoms and what makes them worse?
- Quality and Quantity —what do the symptoms feel like and how often do they appear?
- Region —where are the symptoms located? Does the pain remain in one place or does it radiate?
- Severity —how severe are the symptoms, and do they impact the patient's ability to perform activities of daily living?
- Time —how long have the symptoms been present and do they become worse at certain times of the day?
A Pain Assessment
A pain assessment is an important part of the initial assessment, but it's also a subjective experience and so the nurse should use their experience, in combination with pain scales, to determine how serious the problem is.
Some of the signs of serious pain include:
- Loud moaning and groaning
- Pacing up and down
- Nausea and/or vomiting
- Changes in respiratory rate
- Heavy panting
- Contorted facial expressions
- Clenching/grinding of the teeth
- Grasping an area of the body
- Unable or unwilling to open their eyes or talk
- Changes in blood pressure
A Mental and Physical Examination
Both a physical assessment and a mental health assessment are conducted. The patient's vital signs may be checked (blood pressure, heart rate) and the nurse will look for signs of illness while asking questions relating to both physical and mental health.
Some aspects of the physical assessment may include personal hygiene and grooming checks, as well as body odor and breathing, both of which could hint at problems with physical and/or mental health.
The Focused Assessment
The next stage of the assessment process is to highlight and expose the patient's illness. Their vital signs will continue to be monitored and if they are suffering from any pain or discomfort, that may be relieved with medication.
The patient is made comfortable and a closer physical exam may be performed to confirm the exact nature of their condition.
The Time-Lapsed Assessment
A time-lapsed health assessment is conducted after a treatment plan has been created and implemented. The purpose of this assessment is to record the patient's reactions and to ensure their care is progressing safely and effectively.
This stage of the assessment process could last anywhere from a few hours to several months, depending on the patient's medical diagnosis and how well they respond to treatment.
The Emergency Assessment
An emergency assessment may occur outside of a clinical setting and is used to evaluate the patient's health in an emergency. Their respiratory rate and circulation may be checked and their vital signs will also be monitored.
Tips on Conducting a Patient Assessment
The following tips will help you to correctly perform an initial and ongoing assessment:
Collect all Necessary Documentation
Record the patient's name, date of birth, medical record number, medical history, and anything else that's relevant. All this information will help you with the next steps and should be recorded diligently.
Establish a Strong Nurse-Patient Relationship
Your time with the patient may be very limited, but that doesn't mean you should treat them like machinery on a production line. Be warm, open, and try to develop a rapport. The more of a connection that you can establish with the patient, the more information you'll get from them.
Assess Their Level of Pain
Conduct a pain assessment to determine their level of pain. Ask them to give you a number on the pain scale and encourage them to describe the type and location of the pain as clearly as they can.
Record their Medications
Not only can medications lead to current health problems, but they can also cause reactions when combined with future treatments. It's imperative, therefore, to know exactly what a patient is taking and how much of it they are consuming.
Pay Attention to Non-Verbal Cues
You can't always rely on the patient to tell you what's bothering them. They may overlook or misunderstand some things. They may be downplaying their level of discomfort or hiding certain information from you.
To properly assess patients and ensure you have all the data you need, pay attention to non-verbal cues.
How is their body language when they're talking to you? How are they reacting to your questions? Did they wince during the physical examination or hesitate when you asked them a question about their health?
Some of the most severe symptoms are triggered by allergies, so it's important to ask about these during the initial assessment. Inquire about foods they have eaten or drugs they have taken, as these could have caused their symptoms.
Don't Neglect the Mental Status of the Patient
Even if the patient is presenting with a physical ailment, it's important to pay attention to their mental and emotional health. Are they agitated, anxious, or distressed? Is there any risk of suicide? Are they presenting with any symptoms of substance abuse, including drunkenness or drug withdrawal?
Use Whatever Patient Assessment Tools You Have Available
Patient assessment tools can help you to perform your duty. These tools include:
- A cough assessment
- A scale covering the activities of daily living
- Health questionnaires
- Morse Fall Risk
- NIH Stroke Scale
- The Glasgow coma scale
- Pain scales (including the Faces Pain Scale and the Numeric Rating System)
- Vital sign flow charts
- Dysphagia screen
Clarify and Summarize
If the patient makes an ambiguous statement, ask for clarification. If they seem unsure about a question you have asked, repeat it, and provide more detail.
At the end of the assessment, summarize all of your key findings and provide the patient with information regarding the next steps.
Summary: Why is it Important to Assess a Patient with the Initial Assessment?
The initial assessment is the first thing that a registered nurse does and it sets them up for everything else that follows. It establishes the patient's condition and level of comfort and records essential information such as their blood pressure and mental health status.
It's common across all fields of nursing and is something you'll be tasked with conducting when you move into nursing care.
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