What is a nursing assessment?
A nursing assessment is a process where a nurse gathers, sorts and analyzes a patient’s health information using evidence informed tools to learn more about a patient’s overall health, symptoms and concerns. This includes considering the patient’s biological, social, psychological, cultural and spiritual values and beliefs. A nurse then documents and interprets this information to inform the patient’s care plan and ongoing decision-making about the patient’s health status, which may include identifying urgent, emergent and or life-threatening conditions.
Assessments are critical to patient safety because lack of nursing assessments can pose a patient safety risk. Timely and appropriate holistic nursing assessment is a fundamental skill that all nurses should demonstrate in any area of nursing practice.
What is included in a nursing assessment?
During a nursing assessment the nurse collect both subjective and objective information using evidence informed tools to assess the patient as a whole. A nursing assessment may include, but is not limited to the following:
- Environmental Assessment
- Cultural Assessment
- Physical Assessment
- Psychological Assessment
- Safety Assessment
- Psychosocial Assessment
Nurses use critical thinking when analyzing the findings of their assessments to inform decisions about a patient’s plan of care. Recognizing normal and abnormal patient physiology helps nurses to prioritize interventions and care delivery. Nurses also consult and collaborate with the broader healthcare team to inform their decisions to support safe patient care.
Nurses are accountable to reassess patients frequently to make sure the care plan still meets the patients needs and address any changes to the patients’ health condition. Consistently reassessing patients is a key component to maintaining patient safety and improving patient health outcomes. Not doing so, may pose significant risks to their health.
