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Client Services Nursing Assessment

Nursing Assessment

Nursing Assessment is very important and is considered to be the first step in the process of individualized nursing or personal care. It provides information that is critical to the development of a plan of action that enhances personal health status.

With this form nurses and other health care workers are able to establish baseline data and the patient’s current health condition before providing care. Nursing Assessment can be carried out in hospital, long term care, community or home settings.

In the nursing assessment the following are the possible headings that can be included.

• Allergies to certain medications, food are important in order to avoid allergic reactions.
• Cultural and spiritual beliefs are important. Our front line workers provide care to various clients who are from different cultures, so we need to show respect for each individual's culture and beliefs while providing care.
• Family History is important as this provides information about the client's susceptibility to certain familial and chronic diseases.
• Primary medical diagnosis and secondary medical diagnosis
• Demographic Data e.g. Name, D.O.B., Address, Phone No.
• System Assessment i.e. Cardiovascular, Eyes, Ears, Nose & Throat, Endocrine, Gastrointestinal, Genitourinary, Integumentary ( skin) Musculoskeletal, Neurological, Respiratory
• Pain Assessment
• Specific Client Requests:
  1. Need for elimination
  2. Need for energy balance (e.g. avoidance of fatigue)
  3. Need for self worth
  4. Need for oxygenation
  5. Need for nutrition
  6. Need for connection (e.g. feeling of belonging)
  7. Need for purpose (making meaning of life’s events & challenges)
• Client’s Environment- this refers to the internal dimension and external surroundings that affect the health of the client. It involves a number of contexts in which the client exists: familial, social, cultural, physical, global, historical, community resources available.
• Client’s knowledge of rights and responsibilities: NHI involves the Client, the Family and other Caregivers in the development and implementation of the Client’s Treatment Plan. NHI will seek consent for treatment and consent for information sharing. Additionaly, NHI will emphasize to the Client and the Family (a) the significance of continuity and a team approach to caring for the Client and (b) the significance of a Treatment Plan.
• Client Safety: this involves the need for all people’s protection against harm, and for safety and security.