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Nursing assessment is the gathering of information about a patient's physiological, psychological, sociological, and spiritual status by a licensed Registered Nurse. Nursing assessment is the first step in the nursing process. A section of the nursing assessment may be delegated to certified nurses aides.
The following areas are assessed through questions asked by the nurse and medical examinations to provide an overview of the individual's health status and health practices that are used to reach the current level of health or wellness. [1] [2] Health Perception and Management; Nutritional metabolic
Pain is often regarded as the fifth vital sign in regard to healthcare because it is accepted now in healthcare that pain, like other vital signs, is an objective sensation rather than subjective. As a result nurses are trained and expected to assess pain.
A nursing diagnosis may be part of the nursing process and is a clinical judgment about individual, family, or community experiences/responses to actual or potential health problems/life processes. Nursing diagnoses foster the nurse's independent practice (e.g., patient comfort or relief) compared to dependent interventions driven by physician ...
SOCRATES is a mnemonic acronym used by emergency medical services, physicians, nurses, and other health professionals to evaluate the nature of pain that a patient is experiencing. Uses [ edit ]
The nursing process is a modified scientific method which is a fundamental part of nursing practices in many countries around the world. [1] [2] [3] Nursing practise was first described as a four-stage nursing process by Ida Jean Orlando in 1958. [4] It should not be confused with nursing theories or health informatics. The diagnosis phase was ...
A patient's self-reported pain is so critical in the pain assessment method that it has been described as the "most valid measure" of pain. [ 2 ] [ 3 ] The focus on patient report of pain is an essential aspect of any pain scale, but there are additional features that should be included in a pain scale.
During nursing assessment, a nurse systematically collects, verifies, analyses and communicates a health care client's information to derive a nursing diagnosis and plan individualized nursing care for the client. [5] Complete and accurate nursing assessment determines the accuracy of the other stages of the nursing process. [6]