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Nursing Assessment

Nursing Assessment is the comprehensive evaluation of a patient's health status, needs, and resources.
It involves the systematic collection and analysis of patient data to identify potential health problems, develop a plan of care, and monitor patient progress.
This process encompasses physical, psychological, social, and spiritual aspects, enabling nurses to provide personalized, evidence-based care.
Nursing Assessment is a crucial component of the nursing process, ensuring patients receive optimal treatment and support throughout their healthcare journey.

Most cited protocols related to «Nursing Assessment»

1
Measuring Inpatient Utilization and Medicare Spending
Cited 48 times
For measuring hospital inpatient utilization, we used DRG-based quantity measures that are designed to reflect “true” medical inputs. (DRG prices are set to reflect the average of patients' hospital-borne costs within a large sample of hospitals.) We included outlier payments, which constitute 3.7 percent of total payments to short-stay hospitals, in our measure of utilization because they represent real resources spent for patients with unusually high health care costs.
For payments to physicians under the Medicare Part B (physician services) program, we relied primarily on relative value units, which Medicare uses as a measure of the amount of time spent on an office visit, for example. In practice, Medicare reimburses physicians in New York more for an office visit than for an identical office visit in Wisconsin by paying more per relative value unit. Our method “undoes” this differential by recreating Part B spending using the same dollar payment per relative value unit whether the doctor is in Wisconsin or New York. Thus, if Part B spending is higher in New York, it's because more services are provided, and not because prices are higher.
Other Medicare spending categories were calculated to measure, indirectly, the actual service provided to the patient. These adjustments relied in turn on the CMS regional wage index as the primary mechanism to adjust Medicare expenditures. The wage index is particularly useful when the price-adjustment mechanism used by Medicare to reimburse providers is too complex to unravel or requires additional data sets (such as nursing home risk-adjustment assessments). This index is the primary means to adjust expenditures for the variety of Medicare spending components exclusive of Part A inpatient and Part B physician payments.
For Medicare outpatient payments, only 60 percent of the base payment is eligible for adjustment by the local wage index. Medicare assumes that 60 percent of expenses represent local purchases (and hence local prices) for employees, rents, and other input costs. The remaining 40 percent of Medicare outpatient payments are assumed to not require local price adjustment because they are bought on a national market.10
A similar logic was used for other categories of Medicare expenditures, although we assumed a 75/25 mix—a rough average among the different categories of expenditures such as nursing homes—rather than the 60/40 mix described above.11 –13 The adjustment factors for these smaller components of overall Medicare spending may be imperfect. But these imperfections have little impact on our overall estimates of Medicare spending because they are small relative to inpatient and physician charges that rely on DRGs and RVUs, respectively.
Gottlieb D.J., Zhou W., Song Y., Andrews K.G., Skinner J.S, & Sutherland J.M. (2010). Prices Don't Drive Regional Medicare Spending Variations. Health affairs (Project Hope), 29(3), 537-543.
Publication 2010
Health Risk Assessment Inpatient Nursing Assessment Office Visits Outpatients Patients Physicians
2
Leveraging Administrative Data for Healthcare Insights
Cited 31 times
Administrative data are a compelling source for the study of population-wide health care utilization, patient outcomes, and organization and system evaluation. In the U.S. several administrative data sources are available to researchers from the Center for Medicare and Medicaid Services (CMS). We used resident level data from Medicare claims and nursing home resident assessments and a facility level resource, the Online Survey of Certification and Reporting (OSCAR) which reports results of the annual certification of nursing homes and contains information regarding nursing home deficiencies as well as information about the nursing home residents in aggregate. In particular, we used the reported total number of nursing home residents and the number of Medicare residents on the day of the survey.
Intrator O., Hiris J., Berg K., Miller S.C, & Mor V. (2011). The Residential History File: Studying Nursing Home Residents' Long-Term Care Histories. Health Services Research, 46(1 Pt 1), 120-137.
Publication 2010
Nursing Assessment Patient Acceptance of Health Care Patients
3
Heart Failure Self-Management Intervention
Cited 8 times
The intervention was delivered in the General Internal Medicine Practice. The educational materials and disease management intervention were previously described in detail, and the intervention is summarized here [15 (link)].
The intervention began with a 1-hour educational session with a clinical pharmacist or health educator during a regular clinic visit. Patients were given an educational booklet designed for low literacy patients (written below the 6th grade level and extensively pre-tested in focus groups and a pilot study [15 (link)]) and a digital scale. The educator and patient reviewed the booklet together, including management scenarios. As part of the educational session, patients were taught to identify signs of heart failure exacerbation, perform daily weight assessment, and adjust their diuretic dose. Because this intervention was aimed at patients with low literacy, the health educator used pedagogic strategies felt to improve comprehension for patients with low literacy [17 ]. For example, the educator had the patient teach back the information [18 (link)], engaged the patient in filling out the notebook, and used brainstorming to help the patient incorporate self-management into their lives.
The educator, patient, and primary care physician collaborated to establish the patient's "good weight" (i.e., where the patient's heart failure was stable) and baseline diuretic dose. The educator then filled in the management plan in the patient's notebook to help the patient better manage weight fluctuations and self-adjust the diuretic dose based on weight (Figure 1). The general plan involved doubling the dosage if weight went up and halving it if weight went down.
The program coordinator then made scheduled follow-up phone calls (days 3, 7, 14, 21, 28, 56) and monthly during months 3–6. The follow-up phone calls, each lasting 5–15 minutes, were designed to reinforce the educational session and provide motivation for the patients. Again, the program coordinator had the patient describe their self-management practices and offered feedback to improve them. Patients experiencing worsening symptoms were scheduled acute visits with their physician. We did not provide specialized nursing assessment, care or medication advice beyond diuretic dosing. If the patient's doctor determined that the good weight had changed, the program coordinator would revise the care plan with the patient.
Patients enrolled in the control group received a general heart failure education pamphlet written at approximately the 7th grade level, and continued with usual care from their primary physician. The only contacts between the research team and the control patients were at enrollment and data collection.
DeWalt D.A., Malone R.M., Bryant M.E., Kosnar M.C., Corr K.E., Rothman R.L., Sueta C.A, & Pignone M.P. (2006). A heart failure self-management program for patients of all literacy levels: A randomized, controlled trial [ISRCTN11535170]. BMC Health Services Research, 6, 30.
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Publication 2006
Clinical Pharmacists Clinic Visits Congestive Heart Failure Diuretics Feelings Fingers Health Educators Motivation Nursing Assessment Outpatients Patient Care Planning Patients Pharmaceutical Preparations Physicians Primary Care Physicians Self-Management
4
Delphi Method Guideline for Nursing Theory Evaluation
Cited 4 times
This research is a methodological study for developing a guideline for the use of the
Delphi method in nursing theories evaluation, indicating procedures for organizing,
searching, selecting and coordinating the activities of theoretical evaluators in
teams. The criteria of collective wisdom and levels of proficiency(5 (link)
) were the reference basis and its elaboration took place in Rio de
Janeiro, RJ, Brazil, between the months of November and December 2019.
The elements used in the methodological frameworks for the design, construction and
testing of guidelines were incorporated, highlighting the following: selecting the
topic and scope; adapting a prototype of a theoretical evaluation strategy
guideline, using the Delphi method; group formation for development; systematic
search for evidence; analysis and synthesis of available evidence and elaboration of
the recommendation(10 (link)
).
The specific procedures for developing the guideline were the following: a simple
review of manuscripts on the use of the Delphi method in theories evaluation and
other applications; interpreting nursing theory evaluation methods(4 (link)
,11
-12 (link)
); selection of the complementary material on the topic of collective
wisdom; compiling and interpreting the results of using a prototype of a theoretical
evaluation guideline developed in a masters thesis by one of the authors,
incorporating features of the Delphi method; elaborating the guideline, taking into
account the principles of construction of guidelines in health and the necessary
adaptations to the theoretical-philosophical object; discussion and review by the
authors; final elaboration of the guideline with diagramming interpretation of
nursing theory evaluation methods.
The prototype developed in the masters thesis had the following stages: (a)
selection of the experts; (b) contact with experts and invitation
for participation by those selected; (c) electronically sending the instrument to
those who agreed to participate; (d) appreciation of theory evaluation items based
on an agreement Likert scale; (e) receiving the answers; (f) qualitative and
quantitative analysis of the results; (g) adaptation of the content for a new round
of theoretical evaluation; (h) forwarding with feedback containing
the data that led to the modification or maintenance of the items to perform a new
evaluation; (i) receiving the answers to the adapted instrument; (j) analysis of the
data from the second version; (l) final construction by consensus; (m) grammatical
and orthographic review and (n) closing the theoretical evaluation.
The masters dissertation that incorporated the use of the prototype evaluated the
Theory of Professional Links(13 (link)
) by Meleis theoretical evaluation strategy(14 (link)
). The study that applied the prototype of the guideline respected the
ethical principles of research contained in Resolution 466/2012 of the National
Health Council, obtaining an approval opinion from the Research Ethics Committee,
under number 3.237.583.
Borel M.C., Lopes R.O., Thofehrn M.B., Nbrega M.M., Arreguy-Sena C, & Brando M.A. (2021). Guideline for incorporating the Delphi method in the evaluation of nursing theories. Revista Latino-Americana de Enfermagem, 29, e3387.
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Publication 2021
Anabolism Ethics Committees, Research Nursing Assessment
5
Nursing Assessments in Adult Hospital Units
Cited 3 times
The target population comprised patients over 18 years old admitted to one of the seven adult hospitalization units in the participating hospital. Special services (intensive care, emergency, operating theatres or resuscitation), home hospitalization, maternal-infant and obstetrics hospitalization units did not form part of this study due to differences in the type of care processes, in the organizational model of these units or in the assessment instruments used.
The unit of analysis was nursing assessments. Thus, the study included nursing assessments of functional capacity (Barthel index), risk of pressure ulcers (Braden index) and risk of falls (Downton scale) in the first 24 h after admission to ensure that data related to the time of admission were obtained for all patients. Otherwise, the exclusion criteria were nursing assessments of patients transferred from other units at the same hospital, or at another hospital because their assessments when hospitalized did not correspond to the initial assessment.
The literature recommends a sample size between 5 and 10 subjects per item to develop and validate assessment instruments [33 (link)]. The items for each instrument considered in the study totaled 21, which means that 210 nursing assessments was the minimum necessary sample size. However, no specific recommendations about sample size were found when combining or unifying several instruments. Notwithstanding, Palese et al. (2016) [11 (link)] used a sample with 1446 nursing assessments for a theoretical work with a similar objective. Therefore, considering that the maximum representativeness of the users of these services was sought, and as the analysis strategy required working with different subsamples, all the nursing assessments that complied with the selection criteria and were made during a four-month period (September 2021–January 2022) were included in this study.
Luna-Aleixos D., Llagostera-Reverter I., Castelló-Benavent X., Aquilué-Ballarín M., Mecho-Montoliu G., Cervera-Gasch Á., Valero-Chillerón M.J., Mena-Tudela D., Andreu-Pejó L., Martínez-Gonzálbez R, & González-Chordá V.M. (2022). Development and Validation of a Meta-Instrument for Nursing Assessment in Adult Hospitalization Units (VALENF Instrument) (Part I). International Journal of Environmental Research and Public Health, 19(22), 14622.
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Publication 2022
Adult Emergencies Hospitalization Infant Intensive Care Mothers Nursing Assessment Patients Pressure Ulcer Resuscitation Target Population

Most recents protocols related to «Nursing Assessment»

1
Comprehensive Nursing Care for Perioperative Psychological Support
Nursing assessment: patients’ psychological problems, acceptability, education level, social background, and other factors are comprehensively assessed, and a personalized professional psychological support intervention model is established according to the negative psychological and psychological needs caused by the uncertainty of the disease. The idea of humanistic care is integrated throughout the nursing process along with evidence-based medical integration design theory, and nursing interventions are carried out by highly skilled charge nurses. Establish ongoing psychological support interventions and health education involving patients, patients’ families, and nurses. Health education: patients and their families are informed of the importance of early treatment, preoperative self-control, postoperative coping styles, and compliance with discharge rehabilitation care. Text materials that are simple to understand have been created, and interactive interventions have been delivered using audio-visual materials like music and commentary. From admission to preoperative, health education was provided 1 to 2 times per day for 20 to 30 minutes. Psychological support intervention: psychological communication with patients based on their ability to receive personalized guidance, encouragement, and suggested treatment methods, and the use of support, understanding, and care, increase patient compliance and trust, to achieve optimal psychological status, alleviate the degree of preoperative psychological stress, improve self-efficacy and enhance operational adaptability. The charge nurse should care for and understand the patient from the patient’s point of view, guide the patient to self-regulate their emotional responses, and avoid negative emotions so that the patient’s psychological pressure is in the normal range to ensure the operation is carried out smoothly. Listen carefully to the patient to ensure that the patient feels loved and respected. The charge nurse has a heart-to-heart talk with the patient twice a week for 30 minutes or more and is actively involved in the patient’s family life.
Yao J., He W., Chen H, & Qi Y. (2023). Nursing effect of continuous nursing intervention based on “Internet Plus” on patients with severe adrenal tumor. Medicine, 102(10), e33187.
Publication 2023
Auditory Perception Charge Nurses Emotions Feelings Health Education Heart Nurses Nursing Assessment Nursing Process Patient Discharge Patients Pressure Rehabilitation Speech Stress, Psychological
2
Orthopedic Nursing Quality Evaluation Indicators
In 2018, based on the previous research and practices of 48 orthopedic nursing quality evaluation indicators [10 (link)], the research team summarized the existing problems, searched domestic and foreign literature, and using the Delphi method formulated 10 orthopedic nursing quality sensitive indicators, such as limb blood circulation evaluation accuracy, posture nursing qualification rate, rehabilitation behavior training accuracy, and deep vein thrombosis incidence rate. The expert authority coefficient of two rounds of expert inquiry was 0.902. The results obtained were credible, with positive coefficients of 0.96 and 1.00. After two rounds of expert consultation, the coefficient of variation was 0–0.27, and the coefficient of coordination was 0.36–0.68 (P < 0.05). Structural indicators (include 1.1 as shown in Table 1) were collected by daily registration, process indicators (2.1–2.4) by field assessment, and result indicators (3.1–3.4) by clinical data statistics (chart review) or satisfaction survey. Each index defines its connotation, evaluation elements, and calculation formula, as shown in Table 1. The evaluation criteria of specialized nursing quality were established, such as limb blood circulation, nerve function, axis turnover operation, plaster fixation patient care operation, spinal cord injury patient handling standards, and various auxiliary equipment use standards according to the indicators.
Zhang W., Huang X, & Huang T. (2023). Individualized Management of Quality of Care in Orthopedic Nurses Based on Sensitive Indicators. Computational and Mathematical Methods in Medicine, 2023, 1950220.
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Publication 2023
Blood Circulation Deep Vein Thrombosis Epistropheus Nervousness Nursing Assessment Rehabilitation Satisfaction Spinal Cord Injuries
3
Factors Influencing Infant Feeding Practices
Data collection was based on the electronic medical records. All children born in the hospital with infant feeding records were included. The study sample was selected by simple random sampling. The response variable was infant feeding. Feeding type upon hospital discharge was classified and grouped as BF, artificial, or mixed. Infants who abandoned exclusive BF were assigned to the artificial or mixed group. Milk feeding was measured at 1, 2, 4, and 6 months postpartum. Exclusive MBF was defined as infants who were fed exclusively drawn/donor breast milk from the mother. In addition, MBF newborns only received vitamin drops or syrups, medications, or minerals [15 ]. Artificial feeding was defined when the breastfed infant was fed only with artificial milk, and mixed feeding was defined when an infant’s feeding combined BF and artificial milk.
The study variables were: (1) socio-demographic (maternal age and country of origin) and (2) obstetric (gestational age, parity, pregnancy risk (based on the Spanish Society of Gynaecology and Obstetrics, classification as low, medium, high/very high determined by healthcare provider. Different factors, such as maternal age, previous medical conditions, previous or actual obstetric history, and lifestyle factors, may affect the mother´s health and/or the developing foetus [15 ]), birth initiation, amniorrhexis type, analgesia, and end of birth); following the recommendations of Devane et al. [16 (link)], (3) perinatal variables (newborn’s sex, birth weight, birth length, cephalic perimeter, umbilical artery pH), and (4) feeding (LATCH breastfeeding assessment tool [17 (link)], EIBF time and feeding type) were included. The time until EIBF was recorded by the midwife who assisted the birth as routine data in the electronic medical record and was categorised into two periods, ≤60 min or >60 min, with a maximum time of 120 min. The LATCH score was measured and recorded on the date of discharge from the hospital. This LATCH scale measures BF efficiency using five items. Each item is given a maximum score of 2 points and a minimum score of 0, with a maximum 10-point score (the acronym LATCH corresponds to: L ‘how well infant latches onto the breast’, A ‘audible swallowing’, T ‘type of nipple’, C ‘comfort’, and H ‘hold-positioning’). To optimise the LATCH analysis, LATCH scores were categorised into two categories: <9 points and 9–10 points. As reported by other authors, a LATCH score ≥8 at 48 h or discharge had a sensitivity of 93.5% and specificity of 92.1%, with these mothers being 9.28 times more likely to BF at 6 weeks postpartum [17 (link)].
Sample size was calculated by assuming a 50% MBF prevalence at 6 months postpartum with 5% precision, a 95% confidence interval (95%CI), and an expected 10% proportion of losses. The sample required 335 women. Finally, randomisation of medical record numbers was performed for the births that occurred during the study period, assigning every individual a number by using a random number generator and then randomly picking a subset of the estimated population.
Mena-Tudela D., Soriano-Vidal F.J., Vila-Candel R., Quesada J.A., Martínez-Porcar C, & Martin-Moreno J.M. (2023). Is Early Initiation of Maternal Lactation a Significant Determinant for Continuing Exclusive Breastfeeding up to 6 Months?. International Journal of Environmental Research and Public Health, 20(4), 3184.
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Publication 2023
Birth Weight Breast Child Childbirth Fetus Gestational Age Health Personnel Hispanic or Latino Hypersensitivity Infant Infant, Newborn Management, Pain Midwife Milk Minerals Mothers Nipples Nursing Assessment Patient Discharge Perimetry Pharmaceutical Preparations Pregnancy Tissue Donors Transcription Initiation, Genetic Umbilical Arteries Vitamins Woman
4
Evaluating Nursing Practice Environments
A self-completion questionnaire composed of two parts was used as data collection tool. Part I was related to the participants’ sociodemographic and professional characterization (gender, age, marital status, educational background, professional status, area of specialty, work context and length of professional experience) and part II was composed of the Scale for the Environments Evaluation of Professional Nursing Practice (SEE-Nursing Practice) [22 (link)].
The SEE-Nursing Practice, built and validated in 2020 [5 ], is composed of three sub-scales. The SEE-Nursing Practice - Structure is the first subscale, composed of 43 items divided into six dimensions; the SEE-Nursing Practice - Process is the second subscale, composed of 37 items divided into six dimensions; and, finally, the SEE-Nursing Practice - Outcome is a subscale with 13 items divided into two dimensions. It should be noted that each item is answered on a Likert-type scale with five options, where one corresponds to “never”, two “rarely”, three “sometimes”, four “often” and five “always” [22 (link)].
The Cronbach’s alpha values of the SEE-Nursing Practice components after the 1st and 4th critical periods of COVID-19 were 0.958 and 0.950 in Structure, 0.918 and 0.920 in Process, and 0.932 and 0.909 in Outcome, respectively.
Ribeiro O.M., Cardoso M.F., de Lima Trindade L., da Rocha C.G., Teles P.J., Pereira S., Coimbra V., Ribeiro M.P., Reis A., da Conceição Alves Faria A., da Silva J.M., Leite P., Barros S, & Sousa C. (2023). From the first to the fourth critical period of COVID-19: what has changed in nursing practice environments in hospital settings?. BMC Nursing, 22, 53.
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Publication 2023
COVID 19 Gender Nursing Assessment Nursing Process
5
Nursing Informatics System for Clinical Decision Support
The PAI is a clinical information system used by nurses to document the nursing process (D'Agostino et al., 2012 (link)). This system allows for the electronic collection of standard and essential data related to nursing care (e.g., nursing assessments, NDs, nursing interventions, and patient outcomes) and patients’ sociodemographic data (e.g., gender and age) (Cocchieri et al., 2018 ; D'Agostino et al., 2019 (link); Sanson et al., 2019 (link)). The PAI, through its integrated and validated clinical decision support system (Zega et al., 2014 (link)), supports nurses’ decision-making process on the basis of the data collected during the nursing assessment, providing suggestions for the choice of NDs and related interventions/outcomes. These proposals can be accepted or rejected, thus preserving nurses’ decision-making autonomy (D'Agostino et al., 2012 (link)). The PAI adopts the standardized NANDA-I taxonomy (Herdman et al., 2014 ), in which NDs are grouped into 13 domains of nursing practice (e.g., safety/protection, nutrition, comfort, and health promotion) and classified as problem-focused NDs, health-promotion NDs, risk NDs, and syndrome NDs according to their characteristics.
The HDR is a tool for collecting information related to each patient discharged from the hospital (Ministry of Health, 2008 ). HDR is useful for the analysis of personal data, hospitalization characteristics, and clinical features of patients. HDR adopts the International Classification of Diseases 9th edition with Clinical Modification (ICD-9-CM; Italian version 2007 based on the English version stored in https://ftp.cdc.gov/pub/Health_Statistics/NCHS/Publications/ICD9-CM/2007/) for the coding of diagnoses and therapeutic procedures.
Cesare M., D’agostino F., Maurici M., Zega M., Zeffiro V, & Cocchieri A. (2023). Standardized Nursing Diagnoses in a Surgical Hospital Setting: A Retrospective Study Based on Electronic Health Data. SAGE Open Nursing, 9, 23779608231158157.
Publication 2023
Diagnosis Gender Health Promotion Hospitalization Nurses Nursing Assessment Nursing Care Nursing Process Patients Safety Syndrome Therapeutics

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More about "Nursing Assessment"

Nursing Assessment is a comprehensive evaluation of a patient's health status, needs, and resources.
This crucial process involves the systematic collection and analysis of patient data, enabling nurses to identify potential health problems, develop personalized care plans, and monitor patient progress.
Nursing Assessment encompasses physical, psychological, social, and spiritual aspects, ensuring patients receive optimal, evidence-based care throughout their healthcare journey.
Key subtopics related to Nursing Assessment include patient history, physical examination, diagnostic testing, risk assessment, and care planning.
Relevant tools and software used in the Nursing Assessment process include Aprotinin-coated vacutainer tubes for sample collection, SAS statistical software (version 9.4) for data analysis, Leksell Model G frames for neurological assessments, and SPSS version 20 for advanced statistical modeling.
By leveraging the insights gained from Nursing Assessment, healthcare providers can deliver personalized, high-quality care that addresses the unique needs of each patient.
This comprehensive evaluation is a cornerstone of the nursing process, ensuring that patients receive the support and treatment they require for optimal health outcomes.