The sample nursing assessment is a useful document that helps in recording the required information related to the patient’s medical, physiological and psychological status. This document is very important for the nursing process where all possible tests are conducted that adheres to the patient’s medical needs and is recorded accordingly. The sample nursing assessment helps assess the patient’s nursing problems and the necessary steps that must be taken to rectify them. This sample assessment gives a clear idea of how the nursing assessment must be conducted.
Sample Nursing Assessment:
Name of Patient: Elaine Walters
Age: 58 years
Under the care of: Dr. Charles
Name of Nurse conducting the assessment: Roberta Burns
Name of Health Care Facility: Wood and Burrow Health Care
Assistive Device used: Wheelchair
What the hospital do
- Wood & Burrow Health Care has the state of the line medical equipments that help determine the root cause of any patient’s problem.
- The facility also provides doctors in various specialized fields as well as highly trained nurses.
- The patient will be assessed thoroughly to ensure that all other health care imperatives are being met.
Purpose of the Nursing Assessment:
The patient, Elaine Walters, has been suffering from knee joint pains for the past 4 months. Dr. Charles has ordered a through examination of the joint and spine. This includes a reflex exam and an x-ray of the joints.
Findings from the Nursing Assessment:
After a thorough medical examination of the patient, Elaine Walters, it has been found that she is suffering from Arthritis and has been ordered appropriate medications for six months. If the problem still persists, then appropriate surgery will be undertaken.
Prescribed Medication: Premarin