What it means
The registered nurse gathers subjective data (what the client says) and objective data (what the nurse observes and measures) through interview, physical exam and records. An admission assessment is complete and detailed; a focused assessment looks at one problem or body system; ongoing assessments check for changes. The findings guide the nursing diagnoses and plan of care.
For the nurse
Initial and ongoing assessment of an unstable client is an RN responsibility and is not delegated. A UAP can collect data such as vital signs and report them to the nurse.
At a glance
| Spanish | valoración de enfermería |
|---|---|
| Also written | nursing assessments |
Related terms
assess
To gather information about a client by looking, listening, asking, measuring and examining.
nursing process
The step-by-step method nurses use to plan and give care: assess, diagnose, plan, implement and evaluate.
plan of care
A written plan that lists a client's problems, goals and the nursing actions to reach them.
medical history
A record of a person's past and present health, illnesses, surgeries, medicines, allergies and family health.