Assessment in Nursing Practice: Methods, Tools, and Skills

This essay provides an overview of assessment methods in nursing and discusses the rationale behind conducting assessment in nursing practice. It explores different tools, models, and frameworks used by nurses in the assessment process. The importance of communication skills and the role of assessment in developing a care plan are also discussed.

Running head: NURSING
Nursing
Name of the student:
Name of the University:
Author’s note

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Assessment in nursing practice is the primary approach in nursing process that involves
the process of collection data from patient related to their physical, sociological, psychological
and spiritual status of patient. Out of the five steps of nursing process, nursing assessment is the
first step of the nursing process. The main purpose of nursing assessment process is to it help to
identify immediate needs of patient and make appropriate care plan. It facilitates nurse to plan
and implement individualized care to patient (Toney-Butler and Unison-Pace 2019). With this
context, the main purpose of this essay is to provide an overview of assessment methods in
nursing and discuss the rationale behind conducting assessment in nursing practice. The essay
will also develop understanding regarding different tools, models and framework used by nurse
to engage in assessment process. In the context of assessment, the essay also looks at personal
and professionals skills used by nurse to enhance the outcome of the assessment process.
Assessment in general is the systematic process of documenting and collecting data from
an individual to make judgment on something. In the field of nursing, assessment process is
necessary to document and collect data related to patient’s health outcome and use critical
thinking to develop appropriate plan of care. During this process, nurses play a role in collecting
both subjective and objective data from patients. Objective data is collected related to vital signs
such as temperature, respiratory rate, blood pressure and heart and pain scores. In addition,
subjective data is collected related to family history, medical history, medication history and
psychosocial history of patient. Data is also collected related to presence of allergies, nutritional
needs and fall risk for patient (Toney-Butler and Unison-Pace 2019). Apart from collection of
data related to physical aspects of illness, psychosocial assessment is also a major part of the
assessment process. This is evaluated by signs of agitation, depression, substance abuse,
restlessness and substance. The significance of collecting psychosocial assessment is that it can

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help to fulfil the provision of holistic care and address both physical and mental needs of patient.
It helps to evaluate whether patients is in a state of mental health or mental illness. Holistic care
approach supports assessment of psychosocial outcome of patients too so that appropriate
psychosocial care and quality of life is provided to patient (Legg, 2011). This is followed by
interpretation and analysis of the data to formulate a nursing diagnosis, develop a care plan
accordingly. According to the Nursing and Midwifery Board of Australia (2017), conducting
comprehensive and systematic nursing assessment is an important component of nursing
practice.
Legg (2011) argues that nursing assessment is necessary to identify suitable interventions
for patient with different health issues. Assessment of patient is important in nursing practice to
identify key health concerns for patient, use clinical judgment to develop appropriate care
priorities for patient and identify interventions to address health concerns for patient. It is used to
collect data on different domains such as fall risk, pain, clinical deterioration, changes in vital
signs and presence of disability. Nursing assessment procedure is a set of customized data and
use of appropriate communication skill is necessary during this procedure to extract as much data
from patient and gain their cooperation during the procedure (Milic et al. 2015). Communication
process is an enabler that can promote risk assessment of patient, manage uncertainties,
facilitated record keeping and documentation and make accurate professional judgment.
Communication skill is an appropriate competence that helps to establish therapeutic relationship
with patient and promote gathering and sharing of information and ideas with patient.
Communication skills can help to collect non-verbal clues related to health issues for patient too
(Ceesay 2018). Nurse can apply multiple communication strategy to collect good history of
patient’s condition. This involves use of active listening skill, reflection, empathy and

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summarizing. This process helps to collect and maintain high quality patient data for further
review and treatment plan (Toney-Butler and Unison-Pace 2019).
The systematic procedure that is involved in nursing assessment involved conducting
both physical and psychosocial assessment. Physical assessment focus on collecting data related
to indicators of pain, cardiovascular, respiratory, gastrointestinal, neuromuscular and
integumentary changes in patient’s body after illness or disease. History taking related to pain or
patient medical history is done by tools like PQRTS tool and SAMPLE tool. The significance of
using tools during assessment process is that it provides structured approach to collect data on
specific domain of health. For example, PQRST supports nurse to detect what provokes (P) pain,
identify quality and quantity (Q) of symptoms, assess region or radiation of symptom (R),
evaluate severity (S) through pain score and analysing the duration or time (T) of symptoms
(Fink and Gallagher 2019, April). Apart from this psychosocial assessment is also done to
evaluate the effect of illness on mental health of patient. During such assessment, nurses mainly
collect data related to cognitive function, sign and symptoms of delusion, change in
concentration and activity levels. This assessment is beneficial in identifying fall risk, suicide
ideation, domestic violence and environmental threats for patient (Urden, Stacy and Lough
2019).
In clinical practice, use of several models like biopsychosocial model, holistic model and
Roper’s 12 activities of living help to accurately complete assessment for patient. The
biopsychosocial model of care emphasizes on understanding of human health from various
contexts. It considers the interaction between biological, social and psychosocial factors on
understanding health and illness (Wade and Halligan 2017). Maxwell et al. (2018) gave the
evidence regarding the efficacy of patient-centred assessment method (PCAM) on quality of

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nurse-led biopsychosocial assessments of patient. Using a randomized controlled trial method
and investigating effect of PCAM tool on ability of nurse to identify physical, mental and social
needs of patient, the study revealed patient’s satisfaction with care as broader needs of patient
was assessed. Biopsychosocial model has gained acceptances for conducting chronic pain
assessment too. Use of this tool by nurse is commendable as nurses are required to provide high
quality holistic care and this tool provides nurse with the scope of adapting holistic approach to
pain management (Bevers et al., 2016).
Another tool that supports nurse in effective record keeping and assessment of unique
needs of patient includes the use of Roper’s 12 activities of living tool. This tool is based on the
Roper-Logan-Tierney (RLT) Model for Nursing which focuses on activities of daily living. It is
a simple assessment tool help that supports nurse to evaluate changes in life of patient after
hospitalization or after diagnosis of any illness. Hence, nurses use their clinical judgment mainly
to assess relative independence of patient in terms of activities of daily living. The 12 areas of
daily living that is assessed through this tool includes breathing, maintaining safe environment,
communication, eating and drinking, washing and dressing, elimination, temperature,
mobilization, work and leisure and sleeping (Holland and Jenkins 2019). As this 12 factors focus
on identifying all aspects that has an impact on activities of daily living, it can be considered as a
holistic model for patient assessment. Research evidence shows widespread use of the Roper-
Logan-Tierney Model for assessment of older people. Elderly people are more vulnerable to
complex health needs and Nelson and Carey (2016) revealed RLT model as an appropriate tool
for people with intellectual disabilities. It is also used in stroke rehabilitation and supporting
assessment of patients with other illness like dementia, chronic obstructive pulmonary disease
and mental illness.

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The success of nursing assessment process is dependent on communication skills like
listening skills, clinical judgment, clinical judgment and direct observation skills. Apart from
this, to ensure that the nursing assessment process proceeds without any interruption, it is also
necessary for nurse to have knowledge about confidentiality requirement, duty of care and
patient advocacy during assessment process. As the assessment data is used and shared with
multidisciplinary health care team, it is crucial for nurse to maintain confidentiality and privacy
of patient during assessment. This means being approachable and showing advocacy to prevent
dissemination of private details of patient to other sources and recording patient’s data in a
confidential manner. According to Duty of Care requirement, it is also necessary for nurse to
actively communicate with patient during assessment and make them aware about any potential
risk to health based on assessment data (Stelfox et al. 2015). Integration of the above knowledge
and skills can help nurse to complete a safe and effective patient assessment.
From the discussion regarding the assessment process done in nursing practice, it can be
concluded that assessment process is an important step from the five step of nursing process to
collect appropriate subjective and objective data of patient and develop appropriate plan of care
to promote health. The essay gave idea regarding the significance of considering holistic
approach to complete nursing assessment and patient documentation process. The discussion
regarding use of different tools in assessment process, it has been found that use of several
models and framework guides nurse to effective conduct assessment process. In future, it is
necessary that nursing students gain knowledge about different models and tools and its use for
different domains of patient assessment.

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References:
Bevers, K., Watts, L., Kishino, N.D. and Gatchel, R.J., 2016. The biopsychosocial model of the
assessment, prevention, and treatment of chronic pain. US Neurol, 12(2), pp.98-104.
Ceesay, B., 2018. The Importance of Assessment and Communication as Fundamental Skills of
Nursing Practice. Links to Health and Social Care, 3(2), pp.24-39.
Fink, R.M. and Gallagher, E., 2019, April. Cancer Pain Assessment and Measurement.
In Seminars in oncology nursing. WB Saunders.
Holland, K. and Jenkins, J. eds., 2019. Applying the Roper-Logan-Tierney Model in Practice-E-
Book. Elsevier.
Legg, M.J., 2011. What is psychosocial care and how can nurses better provide it to adult
oncology patients. Australian Journal of Advanced Nursing, The, 28(3), p.61.
Maxwell, M., Hibberd, C., Aitchison, P., Calveley, E., Pratt, R., Dougall, N., Hoy, C., Mercer, S.
and Cameron, I., 2018. The Patient Centred Assessment Method for improving nurse-led
biopsychosocial assessment of patients with long-term conditions: a feasibility RCT. Health
Services and Delivery Research, 6(4), pp.1-119.
Milic, M.M., Puntillo, K., Turner, K., Joseph, D., Peters, N., Ryan, R., Schuster, C., Winfree, H.,
Cimino, J. and Anderson, W.G., 2015. Communicating with patients’ families and physicians
about prognosis and goals of care. American Journal of Critical Care, 24(4), pp.e56-e64.
Nelson, S. and Carey, E., 2016. The role of the nurse in assessing mobility decline in older
people with intellectual disabilities. Learning Disability Practice, 19(9).

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Nursing and Midwifery Board of Australia 2017. Registered nurse standards for practice.
Retrieved from: https://www.nursingmidwiferyboard.gov.au/Codes-Guidelines-Statements/
Professional-standards/registered-nurse-standards-for-practice.aspx
Stelfox, H.T., Lane, D., Boyd, J.M., Taylor, S., Perrier, L., Straus, S., Zygun, D. and Zuege, D.J.,
2015. A scoping review of patient discharge from intensive care: opportunities and tools to
improve care. Chest, 147(2), pp.317-327.
Toney-Butler, T.J. and Unison-Pace, W.J., 2019. Nursing Admission Assessment and
Examination. In StatPearls [Internet]. StatPearls Publishing.
Urden, L.D., Stacy, K.M. and Lough, M.E., 2019. Priorities in critical care nursing. Elsevier
Health Sciences.
Wade, D.T. and Halligan, P.W., 2017. The biopsychosocial model of illness: a model whose time
has come.