Assessment is the first step in the nursing process. A nurse uses every tool available to gather the information required to write a patient's diagnoses and care plan.
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A patient's chart provides information about his health status. It includes details about the current medical condition, treatment plan, related past medical history and other important data required to create a care plan.
Regular monitoring of a patient's heart rate, blood pressure, temperature and respiratory rate allows the nurse to help prevent life-threatening complications and evaluate a patient's overall condition. Abnormalities can indicate a variety of problems ranging from anxiety to heart failure.
One of the most important assessment tools in nursing is the patient herself. A nurse performs an initial detailed interview to get a full picture of the patient's physical and mental status. A nurse also does shorter interviews throughout the day by asking the patient how she is feeling and other questions about her well-being.
Nurses use every interaction with patients as a way to gather information by observing patients' responses to stimuli. This helps a nurse recognise pain, emotional disturbances and reaction to treatment. It is an especially important tool for patients who are unable to communicate.
Other Health Care Professionals
Communicating with other health care professionals involved in a patient's care is vital to assessment, especially when a patient is transferred from another location. In a hospital setting, a patient may be seen by a doctor, nurse, respiratory therapist, physical therapist or other specialists. Gathering information from all these sources helps the nurse create a well-rounded care plan.
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