Nurses receive training, study and apply patient assessment skills. These skills are the cornerstone of becoming a skilled nurse. Learn the skills and procedures for developing these skills during the first two years of nursing school and clinically honed as student nurses assume greater patient burdens. The “standard of care” as the basis for care includes the following:

Standard 1. Evaluation

In the assessment, the nurse must use all his or her senses. These include hearing, tactile, visual and therapeutic communication. The skull method is most commonly used. In other words, patients are evaluated from head to toe. Nurses must be self-aware of the ability to conduct a thorough assessment. Data collection forms the basis for the next step in diagnostic criteria. The nurse must have all the necessary equipment, such as scales, tape measure, thermometer, sphygmomanometer, stethoscope and pen light. This setting is also very important when evaluating. If customers are nervous or anxious, they may be reluctant to answer questions that the nurse asks or wants to check. Getting a quiet environment is not always possible, especially in an emergency. Therefore, nurses must be very sensitive and try to get as much relevant data as possible to develop a diagnosis of care. For example, when evaluating a client complaining of severe stomach pain, ask them if the last food they eat will give the nurse more information, rather than asking how many siblings they have.

Standard II. diagnosis

Nursing diagnosis is not a medical diagnosis. Medical diagnosis will be the medical condition of "diabetes". However, the diagnosis of care will be “altering tissue perfusion”, which is associated with a reduction in oxygenation in the tissue, as evidenced by the 92% pulse oximetry, secondary to the medical condition of “emphysema”. Nursing diagnosis is a formal statement about how a customer reacts to a real or perceived illness. When making a diagnosis, the nurse attempts to develop steps to help the client mitigate and/or adjust their response to real or perceived disease.

Standard III. Result identification

In the process, nurses use assessments and diagnoses to set goals for patients to achieve higher levels of health. Such a goal may simply be that the patient now understands the protocol for testing their blood glucose, or that the new mother may now have been instructed with the correct breastfeeding method. The nurse must plan the client's goals within the client's capabilities. For example, the goal of a customer to walk normally after two days of knee surgery is unrealistic because the client's knees do not heal completely. However, customers can prove that the goal of using crutches correctly is more realistic. This goal is also measurable because the patient will be in the hospital and the nurse can teach and observe the return demonstration. Therefore, the client's goals or outcomes must also be measurable.

Standard IV. planning

Planning standards are designed around the activities of customers in the hospital environment. Therefore, when patients are free to learn, nurses must plan to teach and demonstrate tasks. This would involve administering an analgesic before learning to walk with a cane or waiting for the patient to complete the meal before teaching how to use the syringe. The atmosphere should be good for customers to learn.

Standard V. implementation

The standard requires nurses to test the methods and procedures of testing to help customers achieve their goals. In implementation, the nurse performs the actions required by the client's plan. If teaching is one of the goals, the nurse will record the time, place, method and information taught.

Standard VI. Evaluation

Evaluation is the ultimate standard. In this step, the nurse determines if the goal originally set for the customer has been met. If the nurse believes that the goal or goal has not been met, the plan must be revised and documented. Therefore, the goal should be timely and measurable. If the client's goal is to successfully use the crutches and the customer is able to perform a repetitive demonstration for the nurse, then the goal is reached.

The above criteria are the cornerstone of the nursing profession. These standards require time and experience to learn and implement. Experience is the best teacher, and nurses should continually strive to pursue superior patient care and recognize how to help patients achieve a higher level of physical and mental health.

Learn more about nursing education in the NET Study Guide.

Nursing Education – Patient Assessment Skills was originally published on Spring