Physicians, pediatricians, dentists, surgeons, and many other health care professionals require the aid of a nurse. The nurse serves as an assistant to everything that the doctor will do, from assisting a patient to sit up to assisting the doctor during surgery procedures. Throughout time, the professional field has required all employed individuals to be assessed for ranking, and this includes a nursing assessment or evaluation.
Nursing Assessment Forms are used to state the observations and the suggestions from a nurse to a patient’s health status. The nurse is expected to use accurate medical terms and detailed explanations for their measured examination.
Sample Nursing Assessment Form
Nursing Health and Safety Assessment Form
Nursing Health Assessment Forms
Nursing Care Health Assessment
Health Care Practitioner Physical Assessment
Patient Checklist Form
Patient Checklist for Discharge
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Importance of Nursing Assessment Forms
Only a registered nurse or a registered health professional is delegated for doing the assessment of a patient’s physical, psychological and cultural state. It is important to complete a nursing assessment form to have a full understanding of what the patient is facing and what he will be needing in the future. The form will vary depending on the state of the patient regarding his illness, medical record and the facilities that he may be using. Before starting the assessment, an interview should be initially done to gain the patient’s trust in opening himself to the nurse. With the aid of a Health Assessment Forms, the nurse will know the severity of the patient’s condition and his inlined medicine prescriptions.
Steps in Assessing a Patient
Medical centers may differ in their patient protocols but there are common steps in assessing a patient with the help of a Nursing Monitoring Form:
- Have the patient’s medical records. This includes the patient’s medical history and the details of his previous admission.
- Do an initial interview. This action will help you, as a nurse, to know the patient even more. Trust and reliability will also be visible on the interviewing sessions as long as you will plaster a friendly smile. Take down important notes that you may use for your observation.
- Assess the patient’s sensory functions. This refers to the patient’s ability to move his muscles, from his eye to his arms and legs. The patient’s blood pressure, temperature, and pulse rate should also be indicated in the assessment report.
- Know the patient’s mental state. Patients with different illnesses are most likely to have different moods. State the mood swings of the patient, hygiene, posture and how he remembers things.
- Observe the patient’s physical form from his hair down to his toenails. This should indicate the color, texture and the accompanying symptoms of a possible disease.
- Do a psychological examination. Check if the patient is experiencing delusions and hallucinations and if it was due to the medicine that he took or just merely due to his illness.
- Know the cultural beliefs of the patient. Some diseases and illnesses are due to the culture’s eating habits of a person. There are also medical procedures that a certain culture do not allow their people to get involved with. So, to assure that you are not crossing boundaries, ask for the beliefs of your patient.
Nursing Task Assessment Form
Example of Nursing Task Assessment
Nursing Assessment Form Sample
Nursing Assessment/Monitoring Form
Nursing Care Assessment Forms
Nursing Care Assessment
Nursing Assessment for Home Care
Initial Nursing Care Assessment
Nursing Risk Assessment Forms
Paediatric Nursing Risk Assessment
Nursing Foot Risk Assessment Form
The Five Main Steps in the Nursing Process
Ensuring the consistency of quality health care is important to health care practitioners and nurses, despite requiring different protocols to follow in every medical center. Here are the steps that nurses follow to meet the needs of their patients.
The Assessment Phase. This is where the gathering of data and information is crucial in knowing the background of the patient. The nurses will conduct interviews and examinations to the patient. The observations are stated and recorded in a Nursing Assessment Form.
The Diagnosing Phase. This is where an intellectual guess or hypothesis of the patient’s health problem is made by the nurse. One patient does not mean one exact diagnosis, a nurse may state multiple symptoms and diagnoses for an individual. The descriptions of the health problem will be stated clearly in a Medical Report Form.
The Planning Phase. This refers to developing a certain action plan to cure the patient. This may include the possible medical procedures that the patient needs to undergo for the cure. The health care professionals may contact the patient for further meeting discussions relating to implementing the needed medical procedure.
The Implementation Phase. This phase happens only when the physicians and the nurse have already agreed on moving towards the plan. The nurse may state a specific date of the surgery and the obligations of the patient with preparing his health for the procedure.
The Evaluation Phase. The nurse will have to use an Evaluation Form to rate how the patient is doing after the medical procedure. The patient’s conditions should be clearly indicated, whether he is stable, or if he is discharged. If there are no improvement in the patient’s condition, the nurse will be requested to repeat the process from the assessment phase again.
Nurses must achieve familiarity with the five common steps since one skipped phase may result in an unexpected patient condition. If the patient or the clients are not satisfied with the service that the nurse and the health care professionals granted to them, they have all the right to complain and submit a Complaint Form to the authority.
Such cases are often settled after giving additional attention to the patient and offering better facilities to cure the patient’s illness. However, not all complaints end well due to the protocol that the nurses are required to follow.
Competence Nursing Assessment Forms
Competence Nursing Assessment Tool Form
Nursing Practice Assessment Intake
Nursing Practice Assessment Framework
Nursing Clinical Assessment
Nursing Assessment Record Form
Nursing Needs Assessment Decision Record
Free Nursing Assessment Forms
Holistic Needs Assessment Template
Patient Outcome of Nursing Service Form
National Nursing Assessment Service Authorization
Common Summary Assessment Report
Comprehensive Nursing Assessment Forms
Nursing Home Comprehensive Assessment Form
Comprehensive Nursing Assessment
Initial Comprehensive Geriatric Assessment
Types of Nursing Assessment Forms
Health Care Practitioner Physical Assessment Form – focuses on the physical state of the patient. A health care practitioner is delegated to observe the patient’s skin condition, the hair, and the body structure. A Holistic Needs Assessment may also be considered under this type of assessment form since it also deals with the physical condition of the patient.
Nursing Monitoring Form – this form is to be used for regular check up to monitor the patient’s statistics and improvements.
Pediatric Nursing Risk Assessment Form – used for assessing a child’s health status and the risks that the hospital is going to take when handling a child in the vicinity. Authorities often look for this type of assessment forms when there are children involved in the medical center.
National Nursing Assessment Service Authorization Form – this form is used by practitioners to assess their eligibility in becoming a professional nurse for a specific country, such as Canada.
Common Summary Assessment Report Form– this is the overall report of the assessment which includes the conclusion of the patient’s condition. The nurse will indicate all the needed details, including the assessments from the five nursing phases, in the form.
Nursing Needs Assessment Decision Record Form– this serves as a document wherein the nurse will state what form of procedure that the doctor decided in line with the assessment records. The patient’s needed medicine and facilities are also stated in this form.
Three Tips in Patient Assessing
Assessing an individual is easy, all you need to do is to judge the person but with the help of your field knowledge as your basis. Here are the tricks of the trade to ease up the process of assessing a patient:
- Ask. Do not think that you are over-assessing the patient. Always remember that the more data you are able to gather, the better your assessment will be. Thoroughly examine your patient and look closely from head to toe for symptoms and diagnoses.
- Follow the protocol. The five nursing phases will be helpful for you as a standard guide in assessing a person. You no longer need to think for random steps to take every time you are assigned to do an assessment.
- Immediately determine the diagnosis. Before you tend to forget what you are thinking, scribble down possible diagnoses of your patient. This may be a knowledgeable guess but you can prove it later on after you have finished the assessment.
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