A nursing assessment is the term used for collecting data about a patient’s physical, physiological and psychological conditions. It reflects the patient’s state of well being in terms of these three aspects and sometimes including even spiritual beliefs. There are assessment techniques for measuring the intangible and tangible aspects quantitatively or qualitatively to identify the level of nursing need required by that person. The dangers may come from an inner or outer stimulus and that stimulus is studied in the nursing assessment alongside the time when it can trigger the symptoms. Thus the symptoms are either potential or actual which the assessment procedure must distinguish precisely.
The document for a nursing assessment should be framed along the guidelines given below for accomplishing a trustworthy base for the patient’s problems. These are:
- Establishing rapport with the patient prior to his nursing examination works wonders as far as developing a mutual bond is concerned. It is highly necessary for confiding on the nurse fully.
- Any previous illness and its risks are important to be noted in this context. It should be also noted what management techniques were employed so that the nursing can take off from there.
- Observation plays the key role and every bodily manifestation, like body temperature and blood pressure, should be observed, measured and interpreted as a part of the nursing assessment.
- The assessment is completed only by a synthesis of the patient’s personal beliefs, perceptions, feeling tone and expectations regarding his whole entity. This coupled with biological quantification produces an intact report.
- The assessment may be done using sophisticated tools like electronic medical record or by simple physical means using paper and pen. It should be, then, documented properly.
- After the entire nursing process, a synopsis must be drawn for the matter to be more intelligibly educative.