15 Steps: A Complete Nursing Assessment
A detailed nursing assessment is a comprehensive examination and evaluation of a patient's physical, psychological, sociocultural, and spiritual health. It serves as the foundation for developing an individualized care plan and providing appropriate nursing interventions. Here is a breakdown of the key components of a detailed nursing assessment:
Biographical Data:
Name, age, gender, and contact information.
Emergency contacts and next of kin.
Chief Complaint/Presenting Problem:
The main reason the patient is seeking healthcare.
A detailed description of symptoms or concerns.
Health History:
Past medical history, including chronic illnesses, surgeries, and hospitalizations.
Medication history, including prescription and over-the-counter drugs.
Allergies to medications or other substances.
Family medical history.
Social History:
Living situation (e.g., alone, with family, in assisted living).
Occupation and work environment.
Substance use (alcohol, tobacco, recreational drugs).
Sexual history and reproductive health.
Support system and social support.
Psychosocial Assessment:
Mental health history, including any history of psychiatric illnesses.
Emotional well-being and coping mechanisms.
Stressors and sources of stress.
Cultural and spiritual beliefs and practices.
Review of Systems:
A systematic review of each body system to identify any symptoms or issues.
Includes cardiovascular, respiratory, gastrointestinal, musculoskeletal, neurological, integumentary, genitourinary, endocrine, etc.
Vital Signs:
Blood pressure, heart rate, respiratory rate, temperature, and oxygen saturation.
Pain assessment using a pain scale.
Physical Examination:
Comprehensive head-to-toe assessment, including inspection, palpation, percussion, and auscultation.
Assessment of skin, head, eyes, ears, nose, throat, cardiovascular system, respiratory system, gastrointestinal system, musculoskeletal system, neurological system, etc.
Functional Assessment:
Assessment of the patient's activities of daily living (ADLs).
Mobility and range of motion.
Cognitive function and orientation.
Nutritional status and dietary habits.
Laboratory and Diagnostic Tests:
Review and interpretation of relevant laboratory results and diagnostic tests.
Nursing Diagnoses:
Identification of actual and potential health problems based on assessment findings.
Risk Assessment:
Identification of potential risks such as falls, pressure ulcers, and infection.
Collaborative Problems/Complications:
Identification of potential complications that may require collaboration with other healthcare professionals.
Patient Goals and Preferences:
Establishing patient-centered goals and understanding patient preferences.
Documentation:
Accurate and timely documentation of assessment findings, including any changes in the patient's condition.
A detailed nursing assessment is an ongoing process that evolves as the patient's condition changes. It forms the basis for the development of a nursing care plan and facilitates effective communication among healthcare providers involved in the patient's care.
