NURSING ASSESSMENT

ZARINA BT. ABD. RAHIM

WHAT IS NURSING ASSESSMENT??

Assessment is the first stage of the

nursing process in which the nurse

should carry out a complete and

holistic nursing assessment of every

patient's needs.

EVERYONE ASSESS DIFFERENTLY

Nursing assessment, an identification by a nurse of the needs, preferences, and abilities

of a patient. Assessment includes an interview with an observation of a patient by the nurse and considers the symptoms and signs of the condition, the patient’s

verbal and non verbal communication, the patient medical & social history, and any

other information available.

Sometimes things don’t look like what they are….

Physical aspect assessed are…

•Vital signs

•Skin colour & condition

•Motor & sensory nerve function

•nutrition

•Activity

•Elimination

•Conciousness

EXPECT THE UNEXPECTED……

Among the social and emotional factors, included in assessment are religion,

occupation, family ties & responsibilities.

Assessment is extremely important because it provides the scientific basis for a

complete nursing care plan.

Watch for early warning signs

HOW TO ASSESS ?Introduce to you Sri Kota Specialist Medical Centre’s

new Nursing Assessment form for Adult Admission.

We can assess patient condition as guided by this

assessment tool. The tool is not designed to replace

‘specialized assessment’ that you may already use.

(eg. pressure sore assessment form, high risk patient

assessment form) Instead this assessment form

should act as triggers for ‘specialized assessment’. For example, an assessment of pain control may

trigger the need to undertake a further assessment

using a recognised ‘pain assessment tool’

JUST FOLLOW THE DIRECTION

20

Clubbing fingers

The nursing Process utilizes the following :

• Assessment • Nursing diagnosis • Planning • Implementation • Evaluation

“ When an apple is cut, others see seeds in the apple. We as

nurses, see apples in the seeds.”

– MARTHA ROGERS (Nurse Theorist)

When is the last time anyone check on this patient??!!...

ANY QUESTION??

THANK YOU