看護評価

Nursing assessment includes initial, focused, emergency, and time-lapsed types. Initial assessment occurs soon after admission and collects comprehensive health data. Focused assessment targets specific problems and may identify new issues during routine evaluation. Emergency assessment addresses life-threatening situations requiring immediate intervention. Time-lapsed assessment involves periodic reassessments to compare current health status against baseline data.

A focused assessment gathers data about a specific health problem and can occur during the initial assessment if the patient's primary problem surfaces. It is routinely performed as part of ongoing data collection throughout the patient's care. Focused assessments help nurses monitor particular conditions and identify changes in the patient's health status over time.

Assessment priorities are based on four factors: health orientation, developmental stage, culture, and need for nursing. Health orientation examines the patient's health risks and lifestyle characteristics. Developmental stage ensures appropriate assessment, such as milestone assessments in infants. Cultural background, including racial, ethical, religious, and socioeconomic factors, influences how assessments are conducted and interpreted.

Time-lapsed assessments involve periodic reassessments of the patient's current health status to compare against baseline data obtained earlier. These assessments are especially important for patients receiving long-term nursing care, such as homebound patients with visiting nurses. They help identify changes in health status and guide necessary revisions to the care plan.

The initial assessment collects all aspects of the patient's health to establish baseline data and identify the patient's perceived needs and health problems. It establishes priorities for ongoing focused assessments and creates a reference for future comparison. Most institutions have policies specifying the time interval for completing the initial assessment after admission.

Emergency assessments address physiological or psychological crises requiring immediate identification of life-threatening problems. Examples include a patient choking, an unresponsive patient, or someone threatening violence. These assessments prioritize rapid intervention to stabilize the patient's condition before conducting comprehensive data collection.

Nursing assessment uses two information sources: primary and secondary. After gathering information from both sources, interpretation and validation help complete the data collection process. This comprehensive approach ensures accurate understanding of the patient's health status and supports formulating and validating nursing diagnosis for appropriate care planning.