Nursing assessments are part of being a healthcare provider, whether in nursing homes, hospitals, or long term care rehabilitation facilities. A nursing assessment is a standardized process in which a nurse gathers and analyzes a patient’s health information using evidence-based tools. The findings will include details about a patient’s health, symptoms and ailments.
Upon admission into a facility, a registered nurse (RN) usually conducts the nursing assessment. The nurse will gather and input data for each resident assessing the following criteria:
- Social conditions
- Biological conditions
- Psychological health
- Cultural and spiritual values
- Environmental concerns
- Safety concerns
- Physical health
Once the data is gathered, the nurse will then analyze the findings and document them into the facility’s long term care software. After the admissions assessment is complete, the nurse will apply critical thinking skills to develop and form a comprehensive and personalized care plan for each resident while incorporating the evidence-based results.
A study by StatPearls shows that nursing assessments are an essential part of resident safety. This is because the early detection of medical issues enables the identification of medical concerns that need to be promptly addressed or prioritized during care delivery, thus ensuring better resident outcomes.
Nursing assessments have the function of identifying a patient’s health condition so that an appropriate and personalized care plan can be created. For this reason, it includes documenting multiple factors, such as:
- Appropriate level of care that will meet the patient’s needs
- Evaluation of the care response
- Community support
- Assessment and reassessment once the patient is admitted
- Discharge plans
With the help of an efficient long term care software system, nursing assessment results are better organized, more accurate, and allow for rapid sharing of information between different caregivers and across departments. This improves communication between caregivers, enabling them to consult and collaborate easily, thus ensuring the resident receives the highest level of care.
The Different Types of Nursing Assessments
There are various types of nursing assessments conducted throughout a stay with a healthcare provider, including focused assessments, time-lapsed assessments, and emergency assessments. Regardless of the type of healthcare provider, nurses must be familiar with each type of nursing assessment, as it can have a direct impact on a nurse’s efficiency.
In a skilled nursing facility, the first nursing assessment is the five-day assessment, which Medicare stipulates must be conducted within the first eight days of admission. After this initial assessment, facilities must then follow a rigid assessment schedule, which involves conducting the same nursing assessment on days fourteen, thirty, sixty, and ninety during a resident’s stay.
The assessments are used to collect the following resident data:
- The resident’s current physical and mental condition
- The resident’s medical history
- What medication the resident is taking
- How well residents can perform Activities of Daily Living (ADLs), like bathing, eating, dressing, and toileting
- The resident’s speech and decision-making ability
- Physical limitations that the resident may have, such as hearing or vision problems, paralysis, or balancing difficulties
Another critical nursing assessment for skilled nursing facilities is the Minimum Data Set (MDS) 3.0 Assessment, which is performed by an MDS Coordinator during the admissions process. The MDS assessment is critical to ensuring facilities are paid accurately for PDPM reimbursements. For this reason, MDS nurses and the admissions team work in tandem to document the appropriate information needed for an accurate resident profile.
Using an efficient long term care EHR software system also helps MDS nurses to calculate the daily rate during the admissions process, because a resident’s clinical assessment, diagnosis, and the resources needed are all documented in a clear and organized system. This, in turn, will allow caregivers to provide a higher quality of care due to better documentation and communication between staff, thus improving resident outcomes.
Other types of nursing assessments that are used in both long term care facilities and other healthcare settings include:
- Head-to-Toe Assessment – A head-to-toe assessment is usually conducted by a nurse. It examines a patient’s health status for all major body systems. This is a comprehensive physical assessment that identifies a patient’s needs and health concerns. The assessment is usually conducted during primary care visits or annual physical exams. The assessment duration will vary depending on the patient’s health and overall status.
- Focused Assessment – A focused assessment involves stabilizing a patient’s condition and relieving pain as needed. After the initial assessment, the nurse will have realized what health concerns a patient has. They can then focus on treating them accordingly. However, because a patient’s health condition can change sporadically, it is critical that the nurse monitors the patient’s vital signs during all assessments.
- Time-lapsed Assessment – Once a nurse has diagnosed the medical condition of a patient and started implementing a patient’s personalized care plan, they will then conduct a time-lapsed assessment, which evaluates how the patient is reacting to their treatment plan. Depending on the nature of the patient’s condition, this assessment can take a few hours or a few months. Therefore, throughout the patient’s stay, their condition will be monitored and evaluated closely so that regular comparisons can be made using the recorded results.
- Emergency Assessment – During emergency procedures, an emergency assessment is conducted to evaluate a patient’s airway, breathing, circulation, and the cause of the problem. These assessments usually take place outside of healthcare settings with the nurse ensuring there are no negative effects on other people during the emergency rescue process. Should an emergency assessment be a success and the patient’s condition stabilizes, the nurse will then continue and perform a focused assessment.
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5-Step Process for Priority Nursing Assessments
When nurses are pressed for time, they may choose to conduct priority nursing assessments or a Quick Priority Assessment (QPA). The QPA is usually performed at the start of a shift and is used when a nurse does not have sufficient time to complete a detailed assessment. It offers a quick solution for nurses to gather patient data by determining the relative stability and priorities of care. However, in emergencies or if any health concerns are determined, a nurse will follow up with a focused assessment.
While it is important to conduct nursing assessments, it is equally important to ensure that they are conducted accurately. Here we highlight the standardized five-step process used to function as clinical guidelines for nursing assessments:
When a nurse performs an assessment, they must systematically collect and analyze resident data while delivering a high level of care. The collected data includes physiological, psychological, sociocultural, spiritual, economic, and lifestyle information. This allows a nurse to analyze residents on a holistic level, considering all the variables.
A nursing diagnosis utilizes a nurse’s experience and clinical judgment to diagnose a resident’s health problems. The diagnosis reflects the illness that the resident may be experiencing and also highlights the underlying causes behind the problem, such as poor nutrition, anxiety, or family conflicts. These additional factors will be documented in the resident’s care plan, thus allowing for more person-centered care.
The information gathered from the assessment and diagnosis stages allows a nurse to set realistic and achievable goals for the resident in their care plan. Using efficient care plan software will aid the planning process to ensure personalized care plans are tailored specifically to each resident.
Studies show that the planning phase directly impacts resident care due to the resident-oriented goals, which should be:
- Meaningful and Measurable
- Action-Oriented and Attainable
- Realistic and Results-Oriented
Once a resident care plan is created via the nursing home software, nurses can begin implementing and carrying out nursing interventions highlighted in the care plan. This will require different actions, depending on the level of care needed for each resident. While a nurse is implementing care, they will also work towards the continuity of care, so the resident will be prepared when the time comes for discharge.
Out of the many types of nursing assessments, this final evaluation step is the most important. Here, nurses will assess and evaluate a resident’s condition. They will also ensure that the predetermined goals have been met and that positive resident outcomes are achieved.
However, with the ever-changing medical conditions of residents, nurses need to frequently reassess and evaluate their residents while also modifying the resident’s care plan as needed. To help with nursing assessments, nurses can use nursing assessment tools like the Resident Assessment Instrument (RAI), which allows them to identify a resident’s strengths and needs outlined in their personalized care plan.
The Importance of Documenting Nursing Assessments
While nurses conduct their nursing assessments, it is essential to record resident data accurately in the facility’s long term care software. The advantages of accurate documentation include consistent information, which, when paired with a long term care EHR, creates a concise documentation trail due to the standardized format with precise dates and times for each entry.
Other advantages also include improved compliance with regulations and procedures. Should any legal complications occur, the first step will be to show proof of the nurses’ procedures and processes, which are documented in the nursing home software. This will provide the nurse with sufficient evidence that the assessments were appropriately conducted and that documentation processes were inputted and recorded correctly.
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