Patient Assessment

Medical assessments are all about assessing the patients for current and potential problems and this forms the most important part of the nursing practice. Patient assessment involves checking the patients through a physical examination to ascertain the medical condition of the patient. Different techniques are used to gather information like observation, checking palpation, percussion, auscultation, etc.

Medical judgment is used to determine which assessment technique should be used and to what extent a patient needs physical examination.

Patient assessments are of two types-

  1. Primary assessment- checking the airway, breathing, etc. are components of Patient assessment. These assessments are taken for almost all patients.
  2. Focused system assessment- this assessment involves assessing patients as per their peculiar needs.

The medical practitioner or the nurse use patient assessment tools to decide which patient needs which type of assessment.

What Are The Steps Of Patient Assessment?

  1. Read the manual that has instructions for the patient’s clinical assessment nursing. Although a nurse or a medical practitioner may know well what steps to follow, it is always recommended to keep oneself updated with the latest manual at hand. Medical science is an evolving subject and is updated on an almost daily basis.
  2. Do not take pulse rates at face value. The pulse oximetry is used to read the oxygen levels of patients who are conscious although to gives a reading of the blood cells etc. it is not always accurate.
  3. Check and adjust the temperature of your thermometer. If the temperature of your thermometer is not adjusted before taking the readings, you may end up with the wrong readings.
  4. The pain scale is subjective. Take and analyze the values that you get accordingly.
  5. Take consecutive readings. The patient’s conditions may be changing constantly. In that case, you need to keep taking different readings at different times.

What Is The Importance Of Patient Assessment?

Patient assessment of the patient is the most important and the first step in determining the trouble of the patient and how to address the same. This is a pivotal step as this helps in determining the physical, psychological, social, and economic conditions of the patient. These are used to come up with comprehensive and health-related goals specific to the patient.

Any medical plan however simple and lucid would require the basic information of the patient with the help of health assessment questions to ask the patient without which nothing can be drafted in a health plan. This is achieved by way of primary and focused Patient assessment. This lays the ground for preparing a well-informed health plan.

How Do Psychiatrists Access Patients Type?

Psychiatric assessment is the assessment of a patient for carrying on with psychiatric treatment. Psychiatric assessment involves a few basic steps that may involve asking a few questions.

Questions may be related to –

  1. Attention and focus
  2. Orientation to time and place
  3. Reasoning
  4. Judgment
  5. Memory

This may include asking questions like asking the names of the body parts, naming objects, repeat simple phrases.

There are two types of  psychiatric assessments

  1. Montreal cognitive assessment
  2. A mini-mental state examination

Type Of Patient Assessment?

There are many types of assessments. Depending on the problems of the patient, the assessment will be started by the nurse or the doctor. In case the basic assessment turns out good, there may not be any need for further assessment but if the basic assessment shows any problems, then further assessments would be required to get the right understanding of the problem and the proposed health care plan that is to be followed. The following are the types of assessment-

  1. Initial assessment- this is the first kind of assessment and the most general one. This is taken up at the time of getting admitted by the physician or the admitting nurse.

The nurse would check why the patient is here in the first place and for this, the nurse will ask questions about the patient's medical history, family medical background, and social conditions.

  1. Focused assessment- focused assessment is taken by the nurse after the initial assessment. Under this assessment, the nurse already has an idea about the basic problem that the patient is facing and wants to have a deeper understanding of the nature and extent of the problem. This may require additional tests and documents from the patients. It may also require medical information of the family who has similar symptoms as the patient.
  2. Emergency assessment- another type of assessment is the emergency assessment that is required when there is an emergency that requires immediate attention. It can be done by any nurse or medical practitioner who is present at that time. Emergency assessment is made only to ascertain the immediate problem at hand. There may be underlying medical issues that will not be covered under an emergency assessment.
  3. Ongoing assessment- this assessment takes place after the admission of the patient and after ascertaining their problems. Ongoing assessment is an assessment that takes place at all stages of a patient's treatment till the treatment gets over. At times, it takes place even when the treatment is over to take note of the progress that the treatment has brought into the health of the person.

Patient Assessment

The Impact Of Accurate Patient Assessment On The Quality Of Care?

How well a nurse would be able to give treatment and health care plan is dependant on how well the assessment is made. If the assessment is made accurately, then the nurse would be able to chart an accurate and comprehensive, and problem-specific plan which will bring out better results.

Moreover, the basic work of the nurse is to record information not to interpret it. The nurse records things like blood pressure, pulse, temperature, consciousness level, etc. therefore, the nurse must attempt to record all these things in a put-together manner. The nurse after recording all this information can prioritize the care of patients. Therefore, nowadays the correct assessment of the patient is one of the most important qualities that a nurse must-have.

The main objective of the assessment is to determine the way of observing the progress of the patient and detecting the issues that may result in adverse events. Doing this in a proficient and accurate as well as quick manner will ensure the timely and quality treatment of the patient. The nurses who do this can also help and co-operate with the doctor in the best manner.

There are certain areas of assessment where the nurse can put in more efforts to be able to do a good assessment like –

  1. Checking basic physical health which involves whole-body examination.
  2. Making proper respiratory assessment. At least the rules of assessing the circulatory system of the patient.
  3. Basic respiratory assessment should be known to the nurses.

Also, there are assessments for different types of patients, one assessment cannot satisfy the health conditions of different patients. There are different assessment of stroke patient, cognitive assessment for stroke patients scoring, confused patient assessment, nursing assessment for dementia patients, postural assessment scale for stroke patients, psychological assessment for stroke patients, respiratory patient assessment, assessment of a patient with hypertension, etc.

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About Author
Nick

Nick is a multi-faceted individual with diverse interests. I love teaching young students through coaching or writing who always gathered praise for a sharp calculative mind. I own a positive outlook towards life and also give motivational speeches for young kids and college students.

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