Focused assessment
In addition, the nursing assessment may include reviewing the results of laboratory values such as blood work and urine analysis. understanding of medical and nursing plans.current medical and/or nursing management.classifying symptoms as acute or chronic.present complaint and nature of symptoms.Treatments or what treatments were tried in the past or ongoing.Relieving factors or what makes the concern or complaint better.Aggravating factors or what makes the concern or complaint worse.Duration of health concern or complaint.Location of pain or other symptoms related to the area of the body involved.The nurse may employ the use of acronyms performing the assessment: In the focused assessment, the major complaint is assessed. In many cases, the client requires a focused assessment rather than a comprehensive nursing assessment of the entire bodily systems. ĭuring the first part of the personal interview, the nurse carries out an analysis of the patient needs. Therapeutic communication is also facilitated by avoiding the use of medical jargon and instead using common terms used by the patient. the elderly), privacy, distractions, age-related impediments to communication such as sensory deficits and language, place, time, non-verbal cues. The therapeutic communication methods of nursing assessment takes into account developmental stage (toddler vs. The interview proceeds to asking the client how they wish to be addressed and the general nature of the topics that will be included in the interview. A common method of initiating therapeutic communication by the nurse is to have the nurse introduce herself or himself. This will also assure that the person will be as comfortable as possible when revealing personal information. This develops rapport and lays the foundation of a trusting, non-judgmental relationship.
#Focused assessment professional
īefore assessment can begin the nurse must establish a professional and therapeutic mode of communication.
An assessment format may already be in place to be used at specific facilities and in specific circumstances. Prompt recognition of pertinent changes along with the skill of critical thinking allows the nurse to identify and prioritize appropriate interventions. It incorporates the recognition of normal versus abnormal body physiology. Nursing assessment is used to identify current and future patient care needs.
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. (Nurse Journal, 2017) It differs from a medical diagnosis. Vitals and EKG's may be delegated to certified nurses aides or nursing techs. A section of the nursing assessment may be delegated to certified nurses aides. Nursing assessment is the first step in the nursing process. Nursing assessment is the gathering of information about a patient's physiological, psychological, sociological, and spiritual status by a licensed Registered Nurse.