 | The examples and perspective in this article may not represent a worldwide view of the subject. (January 2024) |
Nursing assessment is the gathering of information about a patient's physiological, psychological, sociological, and spiritual status by a licensed Registered Nurse. Nursing assessment is the first step in the nursing process. A section of the nursing assessment may be delegated to certified nurses aides. Vitals[clarification needed] and EKG's[clarification needed] may be delegated to certified nurses aides or nursing techs. (Nurse Journal, 2017[clarification needed]) It differs from a medical diagnosis. In some instances, the nursing assessment is very broad in scope and in other cases it may focus on one body system or mental health. Nursing assessment is used to identify current and future patient care needs. It incorporates the recognition of normal versus abnormal body physiology. Prompt recognition of pertinent changes along with the skill of critical thinking allows the nurse to identify and prioritize appropriate interventions.[1][2] An assessment format may already be in place to be used at specific facilities and in specific circumstances.[3]
- ^ Schreiber 2016, p. 55.
- ^ Bates, Barbara (1995). A pocket guide to physical examination and history taking. Philadelphia: Lippincott. ISBN 9780397550579.
- ^ Ackley 2011, p. 4.