Assessment in Nursing Assignment

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  • Topic: Nursing, Psychiatry, Nursing care plan
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This assignment will discuss and define the role of assessment as a vital tool in the provision of nursing care within the Nursing process. The author will describe sources of information which may inform the assessment process, identify a specific assessment tool used in my area of practice and identify ways of developing a positive professional relationship with the client, during the assessment process.

The assessment process may be defined as the organized and systematic collection and assimilation of data on the patient’s health status through a variety of sources: these include the patient as a primary source, along with their medical records and any information obtained from the family or any other person giving patient care. Secondary sources can be professional journals and medical texts. (Galasko,1997)

The American Psychological Association defines assessment as ‘assess.(nd):to judge or estimate the value ,character ,etc of…’(Apa,2007). Whereas the (Oxford Dictionary for Nurses) defines it as ‘the first stage of the nursing process in which data about patients health status is collected and from which a care plan may be devised’.

Traditionally, the nurse’s role has been has been one of recording but not interpreting observations including blood pressure, pulse, temperature, respiratory rate and consciousness level. Through recording this information accurately, the nurse is able to prioritize patient care, Nursing Times.net (2006).

McCormack et al (2004), argue that ‘assessment is not just the undertaking of a set of technical skills; rather it requires a certain kind of relationship between those who participate in it and with whom we share the purposes and standards of the practice’. In its’ widest sense, assessment permeates all aspects of nursing care. It is not just a detached activity that initiates the ‘nursing process’ or ‘problem solving cycle’, leading to a plan of care, which is implemented and evaluated, it is an ongoing cycle of activity (Ryrie and Norman.2009).

Assessment is central to all types of nursing activity and something common to all types of assessment is the gathering of information. Assessment data customarily describes a person’s baseline observations and appearance or behaviour, or their presentation and performance, or again the form and function of their thoughts and feelings. More broadly, assessment information encompasses a person’s overall sense of self and their position in life, including not only problems and diagnoses but also their assets and strengths (Barker 2004)

The process of assessment can be seen as cyclical, insofar as the nurse is constantly looking for any changes, differences or other information to aid in the evaluation of the patient’s health. This is important as even the slightest detail can point to a change in the patient’s needs and require intervention. There are a variety of terms used to describe the different forms in which assessment takes place.

Global assessment is concerned with the gathering of general information about the patient, e.g. through a more structured interview process or through the construction of a Life Map or Timeline.

Specific assessments can be centered around single, disparate topics which may have had a profound emotional effect on the patients life, eg. the death of a close relative or the circumstances surrounding the first incidence of substance abuse.

Qualitative information is subjective, in that it is personal to the client and has a specific meaning to them in that it acknowledges, ’their words, their story’ Barker(2000).This type of data is more likely to be obtained from a looser type of interview and is more reliant on the patient’s own self–evaluation. (Hall & Trotter, 2008)

Quantitative information is objective, in that it is obtained through more mechanical or systematic means, such as assessment tools and rating scales. Naturally, different people may respond in different ways to...
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