Name of the Procedure:

Nursing Assessment / Evaluation (T1001)
Common name(s): Initial Nursing Assessment, Nursing Evaluation
Technical term: Nursing Assessment / Evaluation

Summary

A Nursing Assessment / Evaluation is a systematic process performed by a registered nurse (RN) to gather, verify, and communicate data about a patient's health status. This process helps in creating a comprehensive care plan tailored to the patient's specific needs.

Purpose

The nursing assessment / evaluation aims to identify and address any medical conditions, health issues, or risk factors. The main goals are to:

• Evaluate the current health status of the patient.
• Identify nursing care needs and potential health problems.
• Develop a personalized care plan to manage and improve health outcomes.

Indications

• New patient admissions
• Periodic health evaluations
• Post-surgery or post-treatment assessments
• Changes in the patient’s health status or condition
• Chronic disease management

Preparation

• Patients may need to provide a complete medical history.
• Patients should bring a list of current medications.
• No specific fasting or medication adjustments are typically required unless specified by the healthcare provider.

Procedure Description

1. Initial Interview: The nurse conducts an interview to gather comprehensive health history, including past medical history, surgical history, current medications, and allergies.
2. Physical Examination: The nurse performs a head-to-toe physical assessment, checking vital signs (e.g., blood pressure, heart rate, temperature), lung and heart sounds, and other relevant physical parameters.
3. Diagnostic Data Collection: Collection and review of any diagnostic tests or lab results available.
4. Health Risk Assessment: Identify any health risks based on the gathered data.
5. Documentation: All findings are documented in the patient’s medical record.
6. Care Plan Development: The nurse develops or updates a care plan based on the assessment findings.

Tools and equipment used can include stethoscope, blood pressure cuff, thermometer, and other basic diagnostic tools. Anesthesia or sedation is not applicable as this is a non-invasive evaluation.

Duration

The nursing assessment typically takes about 30 minutes to an hour, depending on the complexity of the patient's condition.

Setting

The procedure can be performed in various settings such as hospitals, outpatient clinics, long-term care facilities, and even the patient's home.

Personnel

Registered Nurse (RN) and, occasionally, support from licensed practical nurses (LPNs) or nurse practitioners (NPs).

Risks and Complications

Nursing assessments are generally safe with minimal risk. Potential issues might include discomfort during physical examination or misunderstanding/miscommunication of medical history.

Benefits

• Early identification of health problems and risks.
• Development of an effective, individualized care plan.
• Improved health outcomes through timely and appropriate interventions. Benefits are typically realized immediately as the care plan begins to be implemented.

Recovery

No recovery period is necessary as this is a non-invasive procedure. Patients are free to resume normal activities immediately. Follow-up appointments may be scheduled based on the care plan.

Alternatives

• Self-assessment tools and questionnaires (less comprehensive, may miss critical issues).
• Physician or specialist evaluation (may be more costly and less frequent). The alternatives may lack the continuous and holistic approach provided by skilled nursing assessments.

Patient Experience

Patients might feel at ease during the interview but could experience slight discomfort during physical exams (e.g., when measuring blood pressure). Pain management is usually unnecessary, but nurses take measures to ensure patient comfort throughout the process.