Introduction to nursing observation and assessment

Nursing observation and assessment is defined as any evaluation that involves gathering evaluative data through direct observation. To be clear, observational assessments are employed in both educational and workplace settings across sectors and with learners of all ages. Observational evaluations are particularly significant in the health care sector for a variety of reasons, and they are widely utilized in medical and nursing faculties, as well as other health care sector training contexts. Observational assessments, according to many health-care educators, are the most beneficial technique to assess the knowledge and skills of medical professionals in training.

The Advantages of Nursing Observation and Assessments in the Medical Field

“Direct observation of clinical skills is vital to medical student development, improvement, and accuracy in performing appropriate histories, physical examinations, and communication, including information sharing with patients,” according to a recent study by the Association of American Medical Colleges.

Indeed, the Liaison Committee on Medical Education (LCME) requires that a “medical education program include ongoing assessment activities to ensure that medical students have acquired and can demonstrate on direct observation the core clinical skills, behaviors, and attitudes that have been specified in the program’s educational objectives.”

360-degree evaluations, which are observational assessments that seek feedback from all members of a medical team, are also important.

Observational assessments are also highly appreciated in nursing and other areas of clinical practice. Nursing observation and assessment is used to evaluate important qualities such as compliance, teamwork, and communication, among other things.

The following are some of the advantages of observational evaluation in the healthcare field:

• Data Reliability

Because the assessor is actively seeing and recording the employee’s behaviors in context, observational assessments are seen to be more accurate.

• Direct execution of action

Nursing observation and assessment analyze applicants while they are engrossed in the work at hand. Employers can detect any gaps in skills or knowledge that need to be filled by relying on observational evaluations.

• Results

Healthcare employees can receive fast feedback and respond accordingly because the assessment is conducted in real time. This, too, can help to reduce compliance mistakes.

• Assessments are carried out on the job

Observational evaluations, unlike many other types of formal assessments, take place in the workplace. This can help you save money while also increasing the effect of your assessment.

• Excellent for evaluating teamwork

Working in the health-care field is a team effort. No one individual can ever work effectively on their own. This means that health-care education must be able to evaluate teamwork and collaboration, as well as core knowledge and abilities. Observational assessments are particularly useful for assessing teamwork and collaboration abilities.

The Initial Steps in nursing observation and assessment

A comprehensive health assessment has numerous components. Nurses should aim to establish a relationship with their patients before commencing the evaluation by introducing themselves and explaining what they will be doing and why. The patient may be nervous depending on the situation or purpose for the visit and developing a rapport can assist put the client at ease. It’s also crucial to consider the social, cultural, and behavioral elements that influence the patient’s health.

A health history, which includes information about the patient’s past illnesses or injuries (including childhood diseases and immunizations), hospitalizations, surgeries, allergies, and chronic illnesses, is usually the first step in a full health assessment. It also entails determining whether or not the patient’s sickness runs in the family.

Prior to moving to the physical examination, the patient is asked to describe his or her symptoms, when they began, and how they developed. To begin the physical examination, a comprehensive set of vital signs is taken (temperature, heart rate, blood pressure, and respiratory rate).

Knowing What to Look for is Essential

Learning how to be in tune with individual patient characteristics is a vital component of an RN to BSN curriculum, especially with the rise in chronic diseases and the aging population.

Regardless of a patient’s age or health situation, it is crucial for students to grasp and address differences while conducting assessments on distinct populations, such as pediatric and geriatric patients, or patients with specific disease processes and family dynamics.

Critical Thinking Skills in Health Observation and Assessment

Following the completion of the thorough health assessment, the next stage is to compile all of the data, analyze the objective and subjective data, and establish a care plan. Critical thinking abilities are part of a BSN degree’s curriculum, and they will be needed more than ever in the future.

Conclusion

If you’re a nurse, you already know that doing a thorough patient health assessment is a crucial first step in formulating a strategy for providing the best possible care. A nurse’s function and responsibilities include health assessments. The evaluation is a technique for learning about your patient’s concerns, symptoms, and overall health.