What Information Needs to Be Collected during a Nursing Assessment and How Can the Nursing Care Plan Be Evaluated
Therefore, in the health assessment, the nurse must consider all of these dimensions. Whereas nursing assessment is a component of the nursing process, according to Kozier, et al (2004), it is the systematic collection, organization, validation, and documentation of client data for the purpose of establishing a database about the patient’s response to health concerns or illness and the ability to manage health care needs. Assessment is the first step in the nursing process which is and is one of the most important procedures conducted by nursing staff. It is the nurse that is responsible for assessing the patient for problems or care needs. determining when those findings require the attention of a nurse, physician, or another professional. informing the appropriate persons of the findings. and ensuring follow up for the patient. Since assessment is the very basic in the entire cycle of the nursing process, it is important that the assessment should be correct and complete as this provides the baseline that the diagnosis is based on, the plan of the nursing care shall be identified, the specific interventions be applied, and the evaluation of goals if met or unmet be realized. Incorrect assessment will lead to incorrect diagnosis and an ineffective nursing care process that will not satisfy the patient’s health care and nursing needs.Kozier (2004) states that assessing a client’s health status is a major component of nursing care and has two aspects: (1) the nursing health history and (2) the physical examination that can be any of the three types namely: (a) a complete assessment (when a client is admitted to a health care agency), (b) examination of a body system (e.g., the cardiovascular system) and (c) examination of a body area (e. g., the lungs, when difficulty with breathing is observed). The complete body of information about the patient is called the patient database.