Fundamentals of Nursing I

Nursing assessment is the process of collecting, validating, and clustering data. It is the first and most important step in the nursing process. The assessment phase sets the tone for the rest of the process, and the rest of the process flows from it. Assessment identifies a patient’s strengths and limitations and is performed not just once, but continuously throughout the nursing process. After performing initial assessment, you establish your baseline, identify nursing diagnoses, and develop a plan. Then, as you implement your plan, you also assess your patient’s response. Finally, you assess the effectiveness of your plan of care for your patient.

The Purpose of Assessment

• To collect data pertinent to the patient’s health status
• To identify deviations from normal
• To discover the patient’s strengths and coping resources
• To pinpoint actual problems, and to spot factors that place the patient at risk for health problems

Skills Required for Effective Assessment

• Cognitive problem-solving
  Cognitive skills are needed for critical thinking, creative thinking, and clinical decision making. With experience, you will develop your problem-solving skills. Do not limit yourself to one method; instead, select the method that best suits your patient’s needs. Assessment is “doing.”
• Psychomotor
  Psychomotor skills are needed to perform the four techniques of physical assessment: inspection, palpation, percussion, and auscultation.
• Affective/interpersonal Ethical skills
  Affective skills are needed to practice the “art” of nursing. Affective skills are essential in developing caring, therapeutic nurse-patient relationships.

The data collected through assessment is used to plan the patient’s care, but it is important to remember that the data are the patient’s information. Therefore, you are responsible and accountable for your practice following the code of practice for nurses.