Nursing Health Assessment Tools

Assessment is the first step in the nursing process. A nurse uses every tool available to gather the information required to write a patient's diagnoses and care plan.

Charts

• A patient's chart provides information about his health status. It includes details about the current medical condition, treatment plan, related past medical history and other important data required to create a care plan.

Vital Signs

• Regular monitoring of a patient's heart rate, blood pressure, temperature and respiratory rate allows the nurse to help prevent life-threatening complications and evaluate a patient's overall condition. Abnormalities can indicate a variety of problems ranging from anxiety to heart failure.

Patient Interview

• One of the most important assessment tools in nursing is the patient herself. A nurse performs an initial detailed interview to get a full picture of the patient's physical and mental status. A nurse also does shorter interviews throughout the day by asking the patient how she is feeling and other questions about her well-being.

Observation

• Nurses use every interaction with patients as a way to gather information by observing patients' responses to stimuli. This helps a nurse recognize pain, emotional disturbances and reaction to treatment. It is an especially important tool for patients who are unable to communicate.

Other Health Care Professionals

• Communicating with other health care professionals involved in a patient's care is vital to assessment, especially when a patient is transferred from another location. In a hospital setting, a patient may be seen by a doctor, nurse, respiratory therapist, physical therapist or other specialists. Gathering information from all these sources helps the nurse create a well-rounded care plan.