From the Guidelines
A comprehensive nursing assessment should include a thorough evaluation of the patient's physical, emotional, and psychological well-being, as well as their daily functioning, cognitive status, and support systems, as outlined in the most recent guidelines 1. When conducting a nursing assessment, it is essential to consider the patient's overall health status, including their medical history, current symptoms, and any ongoing health conditions. The assessment should begin with a patient interview to collect subjective data, including their chief complaint, current symptoms, medical history, surgical history, medication list, allergies, and social history 1.
Key Components of a Nursing Assessment
- Vital signs, including temperature, pulse, respiration, blood pressure, and pain level
- General appearance and level of consciousness
- A thorough review of all body systems, including cardiovascular, respiratory, gastrointestinal, neurological, musculoskeletal, integumentary, and genitourinary
- Mental status, mobility, nutritional status, elimination patterns, and any signs of distress or abnormalities
- Psychosocial factors, such as support systems, living situation, and emotional well-being
- Functional assessment evaluating activities of daily living and fall risk, particularly for elderly patients
Additional Considerations
The assessment should also take into account the patient's lifestyle, activities of daily living, and rehabilitative potential, as well as their potential for quality of life improvement and ability to learn self-management skills 1.
Regular Reassessment
Regular reassessment throughout care is necessary to track changes in the patient's condition and evaluate the effectiveness of interventions, with reassessments conducted at least every 6 months or more frequently if indicated 1.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Nursing Assessment Framework
A nursing assessment is a comprehensive evaluation of a patient's physical, emotional, and social needs. The following components should be included in a nursing assessment:
- Identifying the purpose of the assessment 2
- Taking a health history 2
- Choosing a comprehensive or focused approach 2
- Examining the patient using the sequence of inspection, palpation, percussion, and auscultation 2
- Interpreting the clinical findings to recognize abnormality or identify a differential diagnosis 2
Core Physical Assessment Skills
Core physical assessment skills necessary for early recognition of changes in patient status include:
- Assessing airway patency
- Measuring respiratory rate
- Evaluating work of breathing
- Measuring oxygen saturation
- Palpating pulse rate and rhythm
- Measuring blood pressure by auscultation
- Assessing urine output
- Assessing level of consciousness
- Evaluating speech
- Assessing for pain
- Measuring body temperature
- Inspecting skin integrity
- Inspecting and palpating skin for signs of pressure injury 3
Holistic Physical Assessment
A holistic physical assessment framework honors the whole person and includes:
- Seven sequential assessment steps: self, space, least invasive, moderate invasive, most invasive, space, and self
- Incorporating self-care and awareness into the preparation and closure of the assessment 4
Person-Centred Care
Person-centred care is essential in assessing patient needs and planning effective care:
- Assessing people's needs
- Care planning
- Stages of care planning
- Benefits of care planning
- Models of care
- Care pathways
- Care clustering in mental health care 5