Nursing Assessment Forms

Nursing assessment forms are important in patient’s planning of care. With this form, nurses and other fellow healthcare workers are able to establish baseline data and patient’s present health condition can also be determined. It can be a questionnaire type or checklist type; questionnaire type is requiring more specific answers which take time to answer while the checklist type offers limited options for answers but takes shorter time to fill up. Other forms are in combination of questionnaire and checklist type because some questions are appropriate to be in either way. Whatever the format, what’s important is that the assessment form is easy to answer and understand.

In the nursing assessment forms, there are lots of health topics that can be asked. The following are the possible topics that can be included:

Immunizations

• The series of immunization completed is very important in assessing the health history of the patient in order to know if this is related to the patient’s present health status. Incomplete immunizations can also have a chance to be completed.

Allergies

• Allergies to certain foods and medications are crucial to know in order to avoid allergic reactions or even worse, an anaphylactic reaction.

History of certain diseases in the family

• This is to know if the patient is susceptible to certain familial and chronic diseases.

Vices

• This is asked to know if there are contributing factors that may have caused the health problem.

Past medical history

• It determines the possible past health conditions that can affect present health status as well as the chance of reoccurrence of the past health problem.

Cultural and spiritual beliefs

• This is important in giving respect to every individual’s culture and belief while giving nursing care.

Signs and symptoms felt from time to time

• This is useful in planning the course of care that needed to be extended in order to relieve signs and symptoms.

Perception of oneself in accordance to present health status

• Through this a nurse can evaluate if the patient is experiencing emotional problem. It’s a part of a nurse’s duty to provide emotional support to the patients.

Physical assessment that should be done by the nurse is also included in the nursing assessment forms. It is composed of inspection, palpation, percussion and auscultation. In this case, physical assessment can be in checklist type. In inspection, the nurse looks for any marked alteration in the skin such as a rash, bruise and wounds. Palpation, on the other hand, feels if there is any mass and tenderness present. Percussion involves tapping the underlying structures to determine the size. And lastly, auscultation enables the nurse to hear if there are any abnormal sounds present. After this, all of the findings are recorded in the form. The nurse can also add other additional observations on the form as long as it is consistent and informative.

Tags: free download, samples

Nursing assessment forms are forms used to gather data about the patient’s physical, mental, emotional and spiritual health but it is used strictly by nurse practitioners. This type of form is an important part in the first step of the nursing process, which is assessment.

Nursing assessment forms are called such because they are used solely by nurses, as opposed to medical assessment forms which are mainly used by doctors. Nursing assessment forms also focus on the nursing needs of the individual and utilizes nursing diagnoses, rather than medical diagnoses of problems. Typically, nursing assessment is done in hospitals and in clinics. Read More