Nursing assessment

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The term care Assessment ( Assessment - . English for evaluation, assessment, evaluation) describes the use of various, also known as assessment strategies, methods within the professional care to assess care-related variables and phenomena in terms of quality of their success or other priorities and subsequent action to initiate and adapt to current care needs. The selection of suitable instruments for the nursing assessment and the classification of individual conditions in the assessment can follow objective criteria, for example fixed assessment scales, but also be based on the subjective expertise of the nursing staff .

The nursing assessment has been anchored both as a term and as a topic in German nursing care insurance since 1996 . Formally, it is not a method of triage .

intention

The use of the nursing assessment or the corresponding assessment instruments serves various purposes:

  • The assessment serves as a systematic and structured basis for the progress of the nursing process . This allows an objective assessment of the current situation to be determined.
  • Based on the assessments of the assessment, the care can be planned, i.e. the need for care, the type of care and the quality of the care offered are determined. This creates the basis for nursing care.
  • Analogous to the requirements that arise from the legal basis for documentation and care planning , the care assessment fulfills legal requirements for care. It also serves as an assessment basis for the need for individual nursing actions by the cost bearers.
  • The assessment instruments have a control function within the practical care, through which actions can be hierarchized and tasks can be assessed according to their necessity and urgency.

requirements

The prerequisites for the use and professional application of the nursing assessment require a basic understanding of the necessity of the measure on the part of the nursing staff as well as specialist knowledge of nursing diagnoses, which enable an evaluation of the results and the targeted use and selection of individual assessment instruments. In addition, nursing staff must be able to supplement quantitative or qualitative results with a hermeneutical understanding of the individual case. The nursing scientific development of assessment instruments requires research competence and practical as well as theoretical knowledge of the subject to be examined. The developed instruments should have a practice-relevant objective and be able to prove their importance for nursing practice on the basis of objective factors, for example economic value, reliability , or applicability.

distribution

In the German-speaking region, both the development and application of the nursing assessment, in contrast to the Anglo-American region, are not yet very advanced. In Switzerland and Germany, the use of assessment instruments is common and is part of basic nursing training.

Positioning in the nursing process

Six-step maintenance process according to Fiechter / Meier

The various models of the nursing process are based on the problem-solving process, a quality control loop , which in principle consists of the recurring activities of collecting information, determining measures, implementing and evaluating the success of the measures. The nursing assessment represents a subordinate step of the nursing process after recording the actual status, can be repeated in all sections of the nursing process and is integrated into the nursing process. For a long time, the care assessment was based exclusively on the care models from Juchli or Krohwinkel , which align care with the needs of the person being cared for ( activities of daily living - ATL). In the meantime, the nursing assessment is also used to assign the various nursing facilities and the options for assuming costs. This is favored in Germany by the inclusion of these criteria for the definition of the need for care in the social long-term care insurance (Section 14 SGB XI).

The nursing process has been widespread in Switzerland since 1981, after the introduction of nursing diagnoses towards the end of the 20th century, nursing assessments that are not related to the ATLs were also introduced there. This includes, for example, the Assessment of Functional Behavioral Patterns / Health Patterns developed by Marjory Gordon , which deals with the qualitative-phenomenological aspects in eleven different behavioral patterns. The theoretically well-founded instrument, which is linked to the nursing diagnoses of the international classification of nursing diagnoses, is known as the basic assessment for making nursing diagnoses and is gaining in importance due to the increasing spread of computer-aided systems for nursing documentation.

Special nursing phenomena / focus assessments

Assessment instruments are specially developed for relevant care problems, functions and risk considerations. Usually, the assessment instruments are assigned to specific nursing phenomena within nursing. For example, there are various risk scales for assessing the pressure ulcer risk , the results of which are used to concretise the nursing diagnosis and to initiate preventive , therapeutic-nursing measures. Other instruments are used to measure the subjective perception of pain , the need for care and the dependence on care.

In addition to the basic recording and evaluation as part of the nursing history and nursing diagnostics, assessment instruments and / or screening methods can also be used for so-called focus assessments. Here, especially in the clinical area, the focus of the care assessment is placed on the care phenomena that regularly arise due to a special illness, for example in COPD or psoriasis . With the introduction of the National Expert Standards since 2001 and the increasing development in the area of risk management in the healthcare system, this area of ​​nursing assessment is attracting increasing attention.

List of common assessment instruments

Common assessment instruments in nursing are:

literature

Basics

  • Bernd Reuschenbach, Cornelia Mahler: Handbook of care-related assessment methods. Huber, 2012.
  • Sabine Bartholomeyczik , Margareta Halek: Assessment Instruments in Nursing: Possibilities and Limits. Schlütersche, 2004, ISBN 3-89993-114-9 .
  • Marjory Gordon, Elisabeth Brock: Handbook of nursing diagnoses. 4th edition. Urban & Fischer bei Elsevier, 2003, ISBN 3-437-26442-7 .
  • Eva-Maria Panfil: Focus: Clinical Nursing Research: Examples of Quantitative Studies. Schlütersche, 2004, ISBN 3-89993-116-5 .

English-language literature

  • Janet R. Weber, Jane Kelley: Health Assessment in Nursing. Lippincott Williams & Wilkins, 2006, ISBN 0-7817-6240-5 .
  • Janet R. Weber: Nurses' Handbook of Health Assessment. Lippincott Williams & Wilkins, 2008, ISBN 978-0-7817-6632-6 .
  • Marjory Gordon: Assess Notes: Nursing Assessment and Diagnostic Reasoning. FA Davis Company, 2008, ISBN 978-0-8036-1749-0 .
  • Jill Fuller, Jennifer Schaller-Ayers: Health Assessment: A Nursing Approach. Lippincott Williams & Wilkins, 2000, ISBN 0-7817-1566-0 .

Further articles

  • Maria Müller-Staub: Nursing needs and electronic patient files. In: Care. 2008 / Volume 21, Issue 4, ISSN  1012-5302 , pp. 211-214.
  • Maria Müller-Staub: Increase in quality through nursing diagnoses? In: teaching care. 2008 / Volume 14, Issue 1, ISSN  1615-1046 , pp. 20-22.
  • Maria Müller-Staub, Ian Needham and others: Quality of nursing diagnoses, interventions and results: Criteria and operationalization of the Q-DIO measuring instrument. In: Care. 2008 / Volume 21, Issue 5, ISSN  1012-5302 , pp. 327–338.
  • Bernd Reuschenbach: Who protects the practice from unsuitable nursing assessments? In: Care. 2008 / Volume 21, Issue 5, ISSN  1012-5302 , pp. 295–298.

Individual evidence

  1. ↑ Marjory Gordon: Assess Notes: Nursing assessment and diagnostic reasoning. FA Davis Company, 2008.
  2. ^ Marjory Gordon, Elisabeth Brock: Handbuch Pflegediagnosen. Urban & Fischer bei Elsevier, 4th edition. 2003, ISBN 3-437-26442-7
  3. ↑ B. Burri, M. Odenbreit, S. Schärer: Electronic care documentation: Nobody wants to return to paper. ( Memento of the original from March 5, 2016 in the Internet Archive ) Info: The archive link was inserted automatically and has not yet been checked. Please check the original and archive link according to the instructions and then remove this notice. In: Nursing. 2010, 103 (4), pp. 16-18, ISSN 0253-0465 @1@ 2Template: Webachiv / IABot / www.pflege-pbs.ch