Nursing Assessment: Why It's Important

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Most nurses see it as a challenging task to make accurate and comprehensive nursing assessment documentation because there are lots of factors that affect the process. A good nursing assessment can be obtained if the nurse has the ability to consider both nurse factors and client factors, and adapt effectively with the situation brought about by these factors.

Most nurses take nursing assessment for granted; even though the topic is constantly being emphasized in lectures. Most nurses are very much preoccupied with medication administration, assisting with medical procedures and carrying out of doctor’s orders, but they fail to realize that the nursing process is the core of their profession, and nursing assessment is the first step. It is necessary to point out that the nursing process involves a step-by-step procedure, thus a poorly conducted assessment will lead to a poorly executed care plan.

Nursing assessment is important, and here’s why:

• It provides basis for formulating nursing diagnoses. Nursing assessment is perhaps the most important step of the process because it will direct you to precisely diagnose a client’s response to illness. Without assessment, the nurse would be unable to determine which aspect of the client’s health needs nursing assistance. It’s also parallel with the medical process, where the physician gathers the necessary data in order to arrive at a medical diagnosis. It’s just like detective work: how can you establish the case if you don’t have evidence to prove it?

• It guides the care plan. The assessment data also helps the nurse in setting the outcome criteria that are needed in the care plan. For example, if the client is experiencing fever, the nurse would accordingly set outcomes related to temperature regulation. 

• It provides baseline for evaluation. Assessment also directs the final step of the nursing process: evaluation. The data that you’ve gathered provides baseline values, and it tells the degree of deviation from the normal values. If the data are accurate and comprehensive, it would be easier for the nurse to set outcome criteria and determine if the client’s condition has improved based on the criteria. 

• It complements other people’s efforts for the patient. Aside from the benefits brought to the nursing process, nursing assessment also helps the other members of the healthcare team; if some piece of data about the client was not uncovered or examined by the other healthcare team members, the assessment data made by the nurse might have the necessary data that would fill it up. That’s the good thing about working with a team; even though each member uses the patient data differently, the data can be used by the whole team.

There are numerous points to consider why nursing assessment is important, but the crucial point is that without accurate and comprehensive assessment, it’s virtually impossible to carry out any nursing care plan.

Nursing Assessment: Only Limited to Vital Signs Taking?

Back in my student days, whenever we go on a duty at a hospital or community health center, our routine of activities is focused mainly on one thing: taking vital signs. Even though there are times when we were given opportunities to perform procedures and give medications to clients, our instructors oftentimes only ask us to take our client’s vital signs. For a time, I thought that nursing assessment was only focused on taking vital signs, and so during that time, whenever the doctor, staff nurse or my own instructor asks me what I know about my client, oftentimes I tell first the vital signs. In some cases, the client’s vital signs are the only data that I know about my client.

Of course, as I began working as a staff nurse, I verified that the nursing routine was more than that. The things that contributed to this were the times I was observing students having their related nursing experience in the units where I was working. When I ask them about information about the clients they were assigned to, they oftentimes limit their answers to vital signs. In fact, some students have vital signs as the only info they have about their clients.

If all nurses in the Philippines are like this, it certainly spells doom. The sad thing about it is that it is true in most clinical scenarios. Most Filipino nursing students just spend their whole duty hours taking vital signs, and nothing more. And so for most students, nursing to them becomes routine… and boring. Sad to say, some even get the impression that nursing is easy.

Maybe this is one of the reasons why most nursing students also fail the Nurse Licensure Exam (NLE). Nursing students graduate without sufficient training to standards of practice. Nursing students are misinformed about the totality of the practice. And for some, their limited perception of nursing practice becomes the major obstacle for positive change.

Who is at fault? Perhaps the teachers are to blame primarily. In my own experience, it is rare to see a clinical instructor deeply immersing students to performing total client care. They just spend their time sitting in a unit’s conference room chatting with their students, and the only time they go out with their students to the station and the clients’ rooms is when they need to get vital signs.

I personally had difficulties teaching students about nursing assessment. In most cases, students who have been used to the “vital signs routine” complain that I ask too much of them. The feedback that I often get when I task them to perform a comprehensive assessment are these:

·         “Isn’t that the doctor’s job?”

·         “Our other instructors only ask us to take vital signs.”

·         “We are only allowed to take vital signs.”

How do we expect nursing education to improve if this is the mindset of our nursing students? I firmly believe that the primary responsibility rests with the teachers. They have the power to enrich, motivate and mold their students to achieve the necessary competencies so that it wouldn’t be a burden to them to unlearn poor ways and re-learn the right way. Assessment, as we should know, is very crucial in formulating an effective care plan, and everything boils down to good assessment. The client’s information is vital for the nurse to identify the client’s needs, and will determine what interventions would suit his/her needs. We should know that in every patient, the nurse must obtain data about (1) the client’s perception of his/her health, and (2) the signs that indicate the way an illness affects the client’s health.

A student nurse with good foundations from a good mentor will result to a competent professional nurse, locally and globally, if the teacher continually motivates himself/herself to integrate excellence and innovation in guiding students to the expected standards of nursing practice. In this way, people ultimately can be assured of better health through quality nursing care.