Nurses do “nursing assessments” all the time. But when I hear nurses talk about this term they seem to be referring to doing a physical exam. Let’s be sure we are talking about the same thing. Just what is a nursing assessment?
Nursing assessment is the first step of the nursing process; the scientific method nurses use to accomplish our goals. It is the foundation of nursing practice. Without it, nurses could not provide care to people to improve, maintain, or recover health, cope with health problems or achieve the best possible quality of life until death. (Royal College of Nursing’s Defining Nursing 2003) After assessing the nursing problems, the RN makes a nursing diagnosis, lists goals and interventions for each nursing problem (referred to as the nursing care plan), implements these interventions and constantly evaluates if the plan worked.
The first part of the nursing assessment is gathering information from the patient, family and/or caregiver. This is called subjective data because it is influenced by the emotions and point of view of the person giving the information. The second part of the nursing assessment is objective data such as physical exams, tests and the medical record. This data is based primarily on fact. Once all the data is collected, the RN analyzes the data and formulates a nursing diagnosis.
Let’s look at some examples:
1. A patient with recent knee replacement surgery complains of pain. The LPN or RN asks the patient questions regarding the location, quality, severity, frequency, timing, any radiation and what makes the pain better or worse. Then a physical exam is done based upon what symptoms the patient gives. For instance, if the pain this patient relates is at his surgical site, the nurse will look for problems with the dressing and the surgical wound. The RN analyzes this information and decides if the patient’s pain is normal for this type of surgery (the nursing diagnosis) and what to do about it. (the nursing plan)
2. The same patient complains of not feeling well. A more intensive assessment must be done than the more straightforward problem of pain at the surgical site above. The LPN or RN asks the patient specific questions about what he means by “not feeling well” focusing on complications the nurse knows are most likely to happen after this type of surgery. Does he have pain, shortness of breath, dysuria, feel warm or nauseated, have diarrhea or constipation? The nurse must examine more areas of the patient’s body to narrow down his problem. The nurse will take vital signs, listen to lung, heart and bowel sounds, check the patient’s calves for increased warmth, erythema and pain with palpation.
A thorough nursing assessment is more than just doing a physical exam. It includes asking the patient specific questions about his symptoms, doing physical exams looking for signs related to those symptoms and finally analyzing this information to make a nursing diagnosis and care plan.