Introduction

Figure 12.1 Nursing assessments are the foundation for efficient and effective patient-centered care. (credit: “Combat Nurses” by Tech. Sgt. D. Clare/U.S. Air Force, Public Domain)

Chapter Outline

12.1 The Nurse’s Role in Assessment

12.2 Types of Assessment

12.3 Collection of Assessment Data

12.4 Cognitive Process for Analyzing Assessment Data

It is a familiar scene that happens countless times each day: a nurse assesses a patient. The information collected about the patient’s health will enable the care team to identify potential problems, diagnose the likely causes, and plan appropriate treatments. At one moment, the nurse may use a specific tool to assess a specific part of a patient’s body, for example, an otoscope to check this patient’s ears. However, the exam room contains numerous other assessment tools and sources of important information that the nurse needs to pay attention to, including the patient and family members or caretakers who have accompanied them. This chapter explores assessment, from the patient’s initial examination to the diverse skills nurses use in gathering data and determining care priorities.