NURSING ASSESSMENT –
HISTORY TAKING
AND PHYSICAL ASSESSMENT
NURSING ASSESSMENT – HISTORY TAKING AND PHYSICAL ASSESSMENT
Nursing assessment is the gathering of information about a patient’s physiological, psychological, sociological and spiritual status.
Assessment is the first stage of the nursing process in which the nurse should carry out a complete and holistic nursing assessment of every patient’s needs, regardless of the reason for the encounter. Usually, an assessment framework, based on a nursing model is used.
The purpose of this stage is to identify the patient’s nursing problems. These problems are expressed as either actual or potential. For example, a patient who has been rendered immobile by a road traffic accident may be assessed as having the “potential for impaired skin integrity related to immobility”.
COMPONENTS OF NURSING ASSESSMENT
1. Nursing History: Taking a nursing history prior to the physical examination allows a nurse to establish a rapport with the patient and family. Elements of the history include:
- Health status
- Course of patient illness including symptoms
- Current management of illness
- Past medical history including family’s medical history
- Social history
- Perception of illness
2. Psychological and social examination: The psychological examination may include:
- Client’s perception (why they think they have been referred/are being assessed; what they hope to gain from the meeting).
- Emotional health (mental health state, coping styles etc)
- Social health (accommodation, finances, relationships, genogram, employment status, ethnic back ground, support networks etc)
- Physical health (general health, illnesses, previous history, appetite, weight, sleep pattern, diurinal variations, alcohol, tobacco, street drugs; list any prescribed medication with comments on effectiveness)
- Spiritual health (is religion important? If so, in what way? What/who provides a sense of purpose?)
- Intellectual health (cognitive functioning, hallucinations, delusions, concentration, interests, hobbies etc)
3. Physical examination: A nursing assessment includes a physical examination: the observation or measurement of signs, which can be observed or measured, or symptoms such as nausea or vertigo, and assessing area of burn and pain which can be felt by the patient. The techniques used may include Inspection and Auscultation in addition to the “vital signs” of temperature, blood pressure, pulse and respiratory rate, and further examination of the body systems such as the cardiovascular or musculoskeletal systems.
DOCUMENTATION OF THE ASSESSMENT
The assessment is documented in the patient’s medical or nursing records, which may be on paper or as part of the electronic medical record which can be accessed by all members of the healthcare team.
Assessment tools
A range of instruments has been developed to assist nurses in their assessment role.
These include:
- Index of independence in activities of daily living
- Barthel index
- Crighton royal behavior rating scale
- Clifton assessment procedures for the elderly
- General health questionnaire
- Geriatric mental health state schedule
Other assessment tools may focus on a specific aspect of the patient’s care. For example, the Waterlow score deals with a patient’s risk of developing a Bedsore (decubitus ulcer), the Glasgow Coma Scale measures the conscious state of a person, and various pain scales exist to assess the “fifth vital sign”.