Nursing assessment is the gathering of information about a patient's physiological, psychological, sociological, and spiritual

Spirituality

Spirituality can refer to an ultimate or an alleged immaterial reality; an inner path enabling a person to discover the essence of his/her being; or the “deepest values and meanings by which people live.” Spiritual practices, including meditation, prayer and contemplation, are intended to develop...

 status.

Stage one of the nursing process

Assessment is the first stage of the nursing process

Nursing process

The nursing process is a modified scientific method. Nursing practise was first described as a four stage nursing process by Ida Jean Orlando in 1958,. It should not be confused with nursing theories or Health informatics...

 in which the nurse carries out a complete and holistic nursing assessment of every patient's needs, regardless of the reason for the encounter. Usually, an assessment framework, based on a nursing model

Nursing theory

Nursing theory is the term given to the body of knowledge that is used to define or explain various aspects of the profession of nursing.-Grand nursing theories:...

 is used.

The purpose of this stage is to identify the patient's nursing problems. These problems are expressed as either actual or potential. For example, a patient who has been rendered immobile by a road traffic accident may be assessed as having the "potential for impaired skin integrity related to immobility".

Nursing history

Taking a nursing history prior to the physical examination allows a nurse to establish a rapport with the patient and family. Elements of the history include: the client's overall health status, the course of the present illness including symptoms, the current management of illness, the client's medical history (including familial medical history), social history and how the client perceives his illness.

Psychological and social examination

The main areas considered in a psychological examination are intellectual health and emotional health. Assessment of cognitive function, checking for hallucinations and delusions, measuring concentration levels, and inquiring into the client's hobbies and interests constitute an intellectual health assessment. Emotional health is assessed by observing and inquiring about how the client feels and what he does in response to these feelings. The psychological examination may also include the client's perceptions (why they think they are being assessed or have been referred, what they hope to gain from the meeting). Religion and beliefs are also important areas to consider. The need for a physical health assessment is always included in any psychological examination to rule out structural damage or anomalies.

Physical examination

A nursing assessment includes a physical examination

Physical examination

Physical examination or clinical examination is the process by which a doctor investigates the body of a patient for signs of disease. It generally follows the taking of the medical history — an account of the symptoms as experienced by the patient...

: the observation or measurement of signs

Medical sign

A medical sign is an objective indication of some medical fact or characteristic that may be detected by a physician during a physical examination of a patient....

, which can be observed or measured, or symptoms such as nausea

Nausea

Nausea , is a sensation of unease and discomfort in the upper stomach with an involuntary urge to vomit. It often, but not always, precedes vomiting...

 or vertigo

Vertigo (medical)

Vertigo is a type of dizziness, where there is a feeling of motion when one is stationary. The symptoms are due to a dysfunction of the vestibular system in the inner ear...

, which can be felt by the patient.

The techniques used may include Inspection, Palpation

Palpation

Palpation is used as part of a physical examination in which an object is felt to determine its size, shape, firmness, or location...

, Auscultation

Auscultation

Auscultation is the term for listening to the internal sounds of the body, usually using a stethoscope...

 and Percussion

Percussion (medicine)

Percussion is a method of tapping on a surface to determine the underlying structure, and is used in clinical examinations to assess the condition of the thorax or abdomen. It is one of the four methods of clinical examination, together with inspection, palpation and auscultation...

 in addition to the "vital signs" of temperature

Temperature

Temperature is a physical property of matter that quantitatively expresses the common notions of hot and cold. Objects of low temperature are cold, while various degrees of higher temperatures are referred to as warm or hot...

, blood pressure

Blood pressure

Blood pressure is the pressure exerted by circulating blood upon the walls of blood vessels, and is one of the principal vital signs. When used without further specification, "blood pressure" usually refers to the arterial pressure of the systemic circulation. During each heartbeat, BP varies...

, pulse

Pulse

In medicine, one's pulse represents the tactile arterial palpation of the heartbeat by trained fingertips. The pulse may be palpated in any place that allows an artery to be compressed against a bone, such as at the neck , at the wrist , behind the knee , on the inside of the elbow , and near the...

 and respiratory rate

Respiratory rate

Respiratory rate is also known by respiration rate, pulmonary ventilation rate, ventilation rate, or breathing frequency is the number of breaths taken within a set amount of time, typically 60 seconds....

, and further examination of the body systems such as the cardiovascular or musculoskeletal systems.

Documentation of the assessment

The assessment is documented in the patient's medical

Medical record

The terms medical record, health record, and medical chart are used somewhat interchangeably to describe the systematic documentation of a single patient's medical history and care across time within one particular health care provider's jurisdiction....

 or nursing records, which may be on paper or as part of the electronic medical record

Electronic medical record

An electronic medical record is a computerized medical record created in an organization that delivers care, such as a hospital or physician's office...

 which can be accessed by all members of the healthcare team.

Assessment tools

A range of instruments has been developed to assist nurses in their assessment role. These include: the index of independence in activities of daily living

Activities of daily living

Activities of Daily Living is a term used in healthcare to refer to daily self-care activities within an individual's place of residence, in outdoor environments, or both...

, the Barthel index, the Crighton Royal behaviour rating scale, the Clifton assessment procedures for the elderly, the general health questionnaire,and the geriatric mental health state schedule.

Other assessment tools may focus on a specific aspect of the patient's care. For example, the Waterlow score

Waterlow score

The Waterlow score gives an estimated risk of a patient developing a pressure sore. It is named after Judy Waterlow.-External links:* The...

 and the Braden scale

Braden Scale for Predicting Pressure Ulcer Risk

The Braden Scale for Predicting Pressure Ulcer Risk, is a tool that was developed in 1987 by Barbara Braden and Nancy Bergstrom. The purpose of the scale is to help health professionals, especially nurses, assess a patient's risk of developing a pressure ulcer...

 deals with a patient's risk of developing a Pressure ulcer (decubitus ulcer), the Glasgow Coma Scale

Glasgow Coma Scale

Glasgow Coma Scale or GCS is a neurological scale that aims to give a reliable, objective way of recording the conscious state of a person for initial as well as subsequent assessment...

 measures the conscious state of a person, and various pain scale

Pain scale

A pain scale measures a patient's pain intensity or other features. Pain scales are based on self-report, observational , or physiological data. Self-report is considered primary and should be obtained if possible. Pain scales are available for neonates, infants, children, adolescents, adults,...

s exist to assess the "fifth vital sign".