The 4 Types of Nursing Assessments
Updated March 10, 2023
Knowing the four types of nursing assessments is an important part of a nurse's medical training. Regardless of the type of medical institution you work for, being familiar with each type of nursing assessment can have a direct impact on your efficiency. Nursing assessments are important medical procedures, but they require knowledge and practice. In this article, we discuss what a nursing assessment is, why they're important, list each assessment and provide tips on how to conduct one.
What is a nursing assessment?
A nursing assessment is a process of gathering relevant patient information by a registered nurse. The information can describe the patient's physical, psychological, sociological and spiritual situation and is usually the first step in the nursing process. The process consists of collecting the data and applying medical and critical thinking skills to create a care plan for the respective patient, based on their exact needs.
The nursing assessment is the first step of the nursing process. The other steps are:
Diagnosis: Based on the information gathered in the assessment, the registered nurse formulates a diagnosis that not only acknowledges the patient's physical issues but also their ramifications on their psychological, social and spiritual state.
Planning: The medical team develops a care plan that includes the objectives for the respective patient's treatment and recovery, the potential outcomes of the treatment and the interventions needed for the treatment to succeed
Implementation: Actually performing all the tasks decided in the planning phase
Evaluation: An analysis of how successful the intervention was and an adjustment on the initial care plan, when needed
Related: 52 Types of Nurses
Why are nursing assessments important?
Nursing assessments are a major part of a registered nurse's role and the data gathered at this stage can significantly affect a patient's health outcome. Aside from evaluating the exact condition that prompted the patient to seek medical care, a thorough nursing assessment can also identify any underlying conditions that the patient did not know about.
Also, by analyzing the effects that a certain medical condition has on the patient's mental, social and spiritual state, they improve the odds of fully rehabilitating the patient by helping both them and their families get through the entire situation with as little mental distress as possible.
4 types of nursing assessments:
The four medical assessments regularly performed on patients are:
1. Initial assessment
Also called a triage, the initial assessment's purpose is to determine the origin and nature of the problem and to use that information to prepare for the next assessment stages. Due to the fact that the rest of the medical process relies on the accuracy of this initial assessment, it is the most thorough phase of the entire process.
It usually consists of getting the patient's medical history and performing a physical exam on them or, in the case of patients with mental issues, performing a psychological assessment. Depending on the patient's condition, the initial assessment may also include recording the patient's vital signs and looking for subtle symptoms that may be signs of an underlying condition.
Related: What Is a Triage Nurse?
2. Focused assessment
After the initial assessment, the medical issue is fully exposed and treated in the focused assessment phase. Given the fact that a patient's condition may rapidly change, especially in an emergency situation, their vital signs are constantly monitored throughout all four assessments. The focused assessment also involves relieving the patient from pain and stabilizing their condition, when needed. Also, depending on the exact nature of the issue, a long-term treatment plan that aims to resolve the root cause is implemented during this phase.
3. Time-lapsed assessment
After the medical condition is properly diagnosed and a treatment plan is implemented, the time-lapsed assessment is conducted to evaluate how the patient reacts to the agreed treatment plan and how their condition is evolving. Depending on the issue, a time-lapsed assessment can last from a few hours to a few months. Throughout this time, the patient is constantly evaluated and their condition is compared to previously recorded parameters to see if the treatment is effective.
Related: Nursing Clinicals FAQ and Tips
4. Emergency assessment
The emergency assessment is performed during emergency procedures, when it is crucial to evaluate the patient's airway, breathing and circulation, as well as the exact cause of the problem. Emergency assessments can take place outside typical healthcare settings and in these situations the registered nurse must also make sure that no other people are negatively affected by the emergency rescue process. If the emergency assessment is a success and the patient's vital signs are stabilized, the next step is usually a focused assessment.
Tips on how to conduct a successful nursing assessment
Consider these tips on how to correctly and efficiently perform an assessment:
Build a personal relationship with the patient. Although time is usually very limited, you should try to personally relate with the patient, as this can establish a relationship based on trust and respect that can make the next steps easier for both the patient and the medical team.
Collect the proper documentation. Begin by getting the patient's name, age, medical record number, main complaint, probable diagnosis and past medical history.
Assess the pain. By using a pain scale, you can ask the patient to describe the severity of the pain they are experiencing.
Check for allergies. Many severe medical symptoms are actually caused by allergies, so before considering any medical treatment you should check if the patient has any known adverse reactions to various foods, medications or environmental factors.
Check what medications the patient is taking. Any subsequent treatment greatly depends on the medications the patient currently takes and their exact dosage.
Perform a psychosocial analysis of the patient. Aside from evaluating their physical state, you should also pay attention to any signs of psychological or social distress that the patient may be experiencing. Any signs that may indicate depression, agitation, hallucinations, suicidal thoughts or substance abuse withdrawal should be noted and incorporated in the treatment plan.
Look for non-verbal cues. Aside from the symptoms that are either directly observed or communicated by the patients, you should also look for other, more subtle signs, like the patient hesitating when answering a question or various grimaces or sounds that they make when moving or when they are being touched.
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