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Nursing admission assessment and examination.

Tammy J. Toney-Butler ; Wendy J. Unison-Pace .

Last Update: August 29, 2022 .

The initial nursing assessment, the first step in the five steps of the nursing process, involves the systematic and continuous collection of data; sorting, analyzing, and organizing that data; and the documentation and communication of the data collected. Critical thinking skills applied during the nursing process provide a decision-making framework to develop and guide a plan of care for the patient incorporating evidence-based practice concepts. This concept of precision education to tailor care based on an individual's unique cultural, spiritual, and physical needs, rather than a trial by error, one size fits all approach results in a more favorable outcome. [1] [2] [3]

The nursing assessment includes gathering information concerning the patient's individual physiological, psychological, sociological, and spiritual needs. It is the first step in the successful evaluation of a patient. Subjective and objective data collection are an integral part of this process. Part of the assessment includes data collection by obtaining vital signs such as temperature, respiratory rate, heart rate, blood pressure, and pain level using an age or condition appropriate pain scale. The assessment identifies current and future care needs of the patient by allowing the formation of a nursing diagnosis. The nurse recognizes normal and abnormal patient physiology and helps prioritize interventions and care. [4] [5]

  Nursing Process

The function of the initial nursing assessment is to identify the assessment parameters and responsibilities needed to plan and deliver appropriate, individualized care to the patient. [6] [7] [8] [9]

This includes documenting:

The nurse should strive to complete:

Summary Nursing Admission Assessment

Physical Exam

Initial Assessment [10] [11] [12]

Steps in Evaluating a New Patient

Which provides the diagnosis most often: history, physical, or diagnostic tests?

History Taking Techniques

Record chief complaint

History of the present illness, presence of pain

P-Q-R-S-T Tool to Evaluate Pain


Pain Assessment

Pain, or the fifth vital sign, is a crucial component in providing the appropriate care to the patient. Pain assessment may be subjective and difficult to measure. Pain is anything the patient or client states that it is to them. As nurses, you should be aware of the many factors that can influence the patient's pain. Systematic pain assessment, measurement, and reassessment enhance the ability to keep the patient comfortable. Pain scales that are age appropriate assist in the concise measurement and communication of pain among providers. Improvement of communication regarding pain assessment and reassessment during admission and discharge processes facilitate pain management, thus enhancing overall function and quality of life in a trickle-down fashion.

According to one performance and improvement outpatient project in 2017, areas for improvement in pain reassessment policies and procedures were identified in a clinic setting. The study concluded compliance rates for the 30-minute time requirement outlined in the clinic policy for pain reassessment were found to be low. Heavy patient load, staff memory rather than documentation, and a lack of standardized procedures in the electronic health record (EHR) design played a role in low compliance with the reassessment of pain. Barriers to pain assessment and reassessment are important benchmarks in quality improvement projects. Key performance indicators (KPIs) to improve pain management goals and overall patient satisfaction, balanced with the challenges of an opioid crisis and oversedation risks, all play a role in future research studies and quality of care projects. Recognition of indicators of pain and comprehensive knowledge in pain assessment will guide care and pain management protocols.

Indicators of Pain

Psychosocial Assessment

The primary consideration is the health and emotional needs of the patient. Assessment of cognitive function, checking for hallucinations and delusions, evaluating concentration levels, and inquiring into interests and level of activity constitute a mental or emotional health assessment. Asking about how the client feels and their response to those feelings is part of a psychological assessment. Are they agitated, irritable, speaking in loud vocal tones, demanding, depressed, suicidal, unable to talk, have a flat affect, crying, overwhelmed, or are there any signs of substance abuse? The psychological examination may include perceptions, whether justifiable or not, on the part of the patient or client. Religion and cultural beliefs are critical areas to consider. Screening for delirium is essential because symptoms are often subtle and easily overlooked, or explained away as fatigue or depression.

Safety Assessment

Therapeutic Communication Techniques Used to Take a Good History

Multiple strategies are employed that will include:

What are examples?

Cultural Assessment

The cultural competency assessment will identify factors that may impede the implementation of nursing diagnosis and care. Information obtained should include:

Physical Examination Techniques

Initial evaluation or the general survey may include:

Secondary Assessment


What are important things to remember about the physical exam?

Diagnostic Studies

Driven by findings on the history and physical examination; options include:

Discharge Planning

Often the initial history and physical examination lead to the identification of life- or limb-threatening conditions that can be stabilized promptly, ensuring better patient outcomes. The sooner the patient is correctly assessed, the more likely a life-altering condition is recognizable, nursing diagnosis formulated, appropriate intervention or treatment initiated, and stabilizing care rendered. Physiological abnormalities manifested by changes in vital signs and level of consciousness often provide early warning signs that patient condition is deteriorating; thus, requiring prompt intervention to forego an adverse outcome, decreasing morbidity and mortality risk. In the fast-paced, resource-challenged healthcare environment today, thorough assessment can pose a challenge for the healthcare provider but is essential to safe, quality care. The importance of a head-to-toe assessment, critical thinking skills guided by research, and therapeutic communication are the mainstays of safe practice.  [13] [14] [15]

Assessment findings that include current vital signs, lab values, changes in condition such as decreased urine output, cardiac rhythm, pain level, and mental status, as well as pertinent medical history with recommendations for care, are communicated to the provider by the nurse. Communicating in a concise, efficient manner in rapidly changing situations and deteriorating patient conditions can promote quick solutions during difficult circumstances. Healthcare providers communicate and share in the decision-making process. The SBAR model facilitates this communication between members of the healthcare team and bridges the gap between a narrative, descriptive approach and one armed with exact details.

Communication using the SBAR Model

Assessment Tools

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Family Health Nursing Assessment Paper Example

How to write a nursing assessment paper

The purpose of a Family Health Assessment Paper is to provide a detailed account of the nursing process and how it was applied in the clinical area.

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Nursing: Learning Needs Assessment


The nursing profession is a very sensitive job and requires a lot of commitment on the side of the practitioners. This is because the jobs deal with life and some silly mistakes can lead to loss of life, permanent injury, or disability on the patient. As a result, many regulations are involved in nursing. There are also very many programs that are set to ensure patient safety. Patient services are the focus of the practice. It is very important to continually update healthcare especially since technology has seen a lot of improvement and changes coming up very frequently. There is always new information being incorporated into the practice of medicine. This is why it has been very critical that healthcare facilities conduct educational needs analyses and use the results to improve. However, the needs of the nurses and other medical practitioners should not be assumed. Pertinent to note is the on–job and work-related training aspect. Lack of training, inexperience, and lack of continuous updating of service can greatly impact the performance of the nurses. This paper looks into the learning needs of Loma Linda Healthcare System to assess whether there are some gaps between the education of nurses and what they ought to be aware of as far as practice is concerned.

Loma Linda Healthcare System

This center is a division of Desert Pacific Health care and it offers medical services to South Carolina veterans. The system was established in 1977 and it has developed into today’s modern facility that is now used to accomplish the three missions of the agency (Kovner, et al, 2009, p. 73), patient care, education and training, and medical research. The center is located in Loma Linda. This is just a very short distance from Loma Linda University. The California medical center is named after Congressman Jerry Pettis. This was a Second World War veteran at the time and worked very hard to bring the center to Loma Linda. This center is very crucial for services such as surgery, psychiatry as major services, and numerous other inpatient and outpatient services (Sibbald & Young, 2001, p. 30). They include Behavior medicine, critical services, cardiac care, MRI, dental care, diabetic services, HIV/AIDS care, dermatology, and oncology among others.

The center also runs home programs. This health facility runs 142-bed services for acute care and 108 units for the home nursing program. This is quite a large volume of activities with about 300,000 servicing veterans.

Medical Home Model

Patient-centered care is very critical just as noted above that patients are the focus of care. Their satisfaction is hence very important. In this regard, there are services for patients that are set to concentrate in homes. Medical home for patients is a model that is designed to offer comprehensive primary healthcare to patients. This model is unique since it has broadened access to this important primary care (Kovner, et al, 2009, p. 74). This means many people can access the services as close are where they stay or live. This is done at the same time enhancing coordination of care. This model is critical since it also demands that clinicians exercise the highest level of service. Clinicians are hence required to

A medical home employs people from different disciplines that are medically related. The qualifications range from a bachelors’ degree to, associate degree, to master’s and even postdoctoral degrees. For instance, to join in for nursing home health program, entry-level jobs, one needs to have a bachelor’s degree in medical or health-related courses from an institution that is accredited by the professional bodies (Sibbald & Young, 2001, p. 30). Loma Linda University, LLU, which is affiliated with this center is already an accredited institution. Masters degrees in courses like clinical epidemiology and other public health categories like Biostatics, Nutrition, preventative care, and maternal childcare are very important for this program especially for those workers who are specialists. Many of the workers tend to come from LLU as its accredited and a member of a professional body the Association of Public Health Schools. Degrees in medicine, nursing, dentistry, and pharmacy are also very necessary for employment by the VA medical home. Gaining Post-doctorate degrees in any of the fields can earn one a position in management. For instance, directors of maternal and childcare should have a master’s degree in obstetrics (De Young, 2009, p. 66). For the director of primary care, one has to possess a master’s degree in medicine or public health equivalent courses.

The Educational Needs Assessment

It is important that in practice, the gaps between what the practitioners know are filled to link with what they should know. This paper assesses the factors that are critical to nursing practice in veteran service (De Young, 2009, p. 66). Hypothesis; even though nursing is essential for the safety of the patients, and there is the constant improvement of service to ensure superior services many nurses still fail to advance their skill even though nursing knowledge continues to improve each day. It’s with this in mind that this research seeks to identify the actual knowledge and training that nurses have and what the latest inventions and discoveries propose. This is what nurses ought to know or train (De Young, 2009, p. 66). Nursing and healthcare services are essential to the community and require regular updating of the information that practicing nurses have and the latest technology being invented in practice.

Many researchers argue that job satisfaction could be the most important factor in comprehending how workers are motivated yet it has remained elusive. Experience, training, and education level are also very critical to the nurses and this can have a very serious impact on the safety of the patients, performance, dedication to the job, quality of services, and worker retention. This study investigated the way nurses perceived their training and experience and other factors that related to that especially on-the-job training, seminar, the introduction of new services, and advancing or specialization (Billings & Halstead, 2009, p. 78).

The objectives of the survey were to identify the level of training and experience that the registered nurses at Loma Linda possess. Regarding this the study also sought to assess whether the nurses undergo continuous training while on the job, have had other qualifications after completing the first degree, attend other training besides the usual curriculum and other training including seminars and workshops among others to improve service. The study also sought to identify the type of learning method that the nurses preferred to use while already in practice to improve performance- work-related learning (Gould et al, 2004, p. 33).

Learning needs assessment is an educational type of research that is more specialized. It offers a chance to discover the gap between the current practice and what is being invented or discovered (desired practice.). Continuing to study when it works is likely to result in a change of practices and quality of service as education is more connected to personal incentives.

Exploratory design was used in the investigation. A cross-sectional approach was applied in the survey to 275 anonymous registered nurses. These nurses were working for Veterans Affairs, Loma Linda system. The sample size was a recommendation by researchers to ensure that the size would allow adequate linear regression. Data were collected from the center after the approval by the Loma Linda Healthcare System and the LLU (Kovner, et al, 2009, p. 71). Eligibility was that one has to be a nurse and an employee of the Loma Linda system. The nurses were also to be registered practitioners. Participants who indicted informed consent were allowed to take part by signing a consent form. The questionnaires were self-administered. The questions were designed to concentrate on the current practice needs and the desired improvement of the model. The center offered rooms where the study was conducted.

The researcher explained to the participant the aims of the study. All the levels of employment were included from those at entry-level to the experienced workers in management. All these workers offer care to inpatients and outpatients. The questionnaire included a basic information section and the professional aspects of the study (Holloway, 2007, p. 9). The second part was called and rated on a standardized scale to help in the evaluation of the results.

The Questionnaire

Basic information.

Name­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­___________________________ Gender__________________________

Age_____________________________ Department______________________

Marital status_____single/married/divorced

Professional features Information

1,2,3,4,5,6,7,8,9, 10,11,12,13,14,15,16,17,18,19, 20,21,22,23,24,25,26,30 +

Professional questions

Rating: 1-Strongly Agree 2- Agree 3- Undecided 4-disagree 5-strongly disagree

Measures – the gaps between the current knowledge and the improved or desired services were assessed based on several factors. These factors included the level of training. The answered were rated on a five-point Likert scale to indicate the level of satisfaction (Farley & Fay, 2001, p. 13).

The outcomes were rated as the Likert scale revealed, ranging from extreme satisfaction to extreme dissatisfaction. All the questionnaires were collected back and the researchers managed to have 275 responses. 39% of the participants were men while 61% were women. The mean age of response was 36 years old. Most of the workers were also married at a rate of 65%. 53.2% of the practitioners had additional nursing specialization (i.e. master’s degrees) after graduation from nursing school with first degrees. 14% of the participants were head nurses and 55.5% were based in in-patient programs (Farley & Fay, 2001 p. 13). Most nurses (65.3%) worked one shift a day, 13.7% worked two shifts and the rest worked on a locum basis or freelance

Almost half (53.6%) of the participants were comfortable with their duties and responsibilities. The rest would like to change their duties to be more comfortable. Most of the participants did not feel adequately trained for the nursing profession. A very great percentage (85%) of the participants indicated that there was a need to continue with training and learning of the best primary care. This included technical and professional skills. A moderately higher number of the participants indicated that they would prefer to learn management skills so that they can be more effective in coordinating care and in decision making (Gould et al, 2004, p. 33).

After assessing the learning needs of the nurses practicing primary care, many of them considered experience as an essential requirement for the practice. 12 percent had associate degrees, 18 have bachelor’s degrees while 45 –percent had specialized with master’s degrees. This outcome is linked to the fact that LLU is affiliated to the institution and the workers easily find access to the education programs of the university (Gould et al, 2004, p. 33). The two institutions work together to improve services. Since the university greatly supports research, new technology usually gets to the facility even faster. Considering that a greater percentage of the workers had other professional training besides their degree qualifications, it’s evident that the need to learn and train is at least trying to keep pace with advances of home medical needs. Learning at work is a great challenge and many of the respondents did not like on-job learning (90%). This is attributed to the fact that in-depth training needs extensive training sessions.

Conclusion and Recommendations

Efficiency is paramount in the administration of medical treatment. This arises from the fact that medical practice deals with the life of individuals. One of the models which contribute towards efficient delivery of medical services is the patient-centered care model. The model enables the patients to receive comprehensive healthcare benefits. For it to be effective, a high degree of flexibility is required. Healthcare providers should be in a position to provide medical care even on short notice. In addition, the practitioners are required to make use of the latest healthcare knowledge and technology and more so the evidence-based model to offer services and update the records. Nursing and healthcare services are essential to the community and require regular updating of the information that practicing nurses have and the latest technology being invented in practice. For practitioners at Loma Linda to be effective, the management team needs to incorporate an education need assessment program. The program should contribute towards the identification of employees’ career development requirements. The resultant effect is that there will be an increment in the level of motivation amongst employees. Apart from employee motivation, learning needs assessment is an educational type of research that is more specialized. It offers a chance to discover the gap between the current practice and what is being invented or discovered (desired practice. This means that the model will be more effective. Educational need assessment should be conducted regularly to identify the changes within nursing and healthcare.

Reference List

Billings, D.M. & Halstead J.A. (2009), Teaching In Nursing: A Guide for Faculty , St. Louis: Elsevier Saunders.

De Young, S. (2009). Teaching Strategies for Nurse Educators (2 nd Ed.). Upper Saddle River: NJ: Prentice-Hall.

Farley JK. & Fay P. (2001). A System For Assessing The Learning Needs Of Registered Nurses, The Journal Of Continuing Education In Nursing ; 19: Pp13-16.

Gould, D., Kelly, D. & White, I. (2004). Training Needs Analysis: An Evaluation Framework. Nursing Standard , 18, 20, 33- 36.

Holloway, K. (2007), Hutt Valley Nursing Training Needs Analysis, Final Report, Health Studies, P 3-27.

Sibbald, B., & Young, R. (2001), the General Practitioner Workforce 2000. Workload, Job Satisfaction, Recruitment , and Retention. Manchester, National Primary Care Research & Development Centre.

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assessment essay nursing

Nursing Leadership: A Self-Assessment Essay

Leadership skills are necessary for building a successful nursing career, providing high-quality health care, and developing a culture of improvement at a facility. Future professionals explore their strengths by studying, practicing, and following the inspiring examples of their teachers or senior colleagues. Self-assessment is another valuable strategy for identifying potential gaps to address for becoming a practical nurse leader. Furthermore, awareness of competencies to seek and develop can help DNP-prepared practitioners create their own leadership improvement goals and tactics to achieve them (American College of Healthcare Executives, 2017). Indeed, influential, communicative, team-building, and executive skills are considered essential for nurses of all types of organizations. This paper aims to conduct a self-assessment in relation to nurse leadership, identify potential strengths and gaps, and set development goals.

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Nursing leadership competencies address effective communication skills, high-quality healthcare providence, rational decision-making, and the ability to be responsible for extended groups of people. Indeed, aspiring DNP-prepared practitioners can assess themselves by identifying if they have sufficient skills to influence others, knowledge of their working environment and safety, and utilize critical thinking (American Organization for Nursing Leadership [AONL], n.d.). Communicational competencies can be expressed through solid organizational expertise, engaging others in specific behaviors, and facilitating discussions (AONL, n.d.). Knowledge of the working environment and the ability to operate in it can be viewed through actions taken to improve the clinical practice and education of others.

I had various opportunities to explore my leadership skills, enhance them, identify the gaps, and reveal my strengths throughout my education and nursing practice. Indeed, at school, I was a team leader of volunteering projects we created to conduct systematic support for homeless people in my local community. Participating in the projects as one of the executives felt normal to me because I have always encouraged people to follow me on any mission. That strong quality of my character was released through the ability to craft speeches and develop empathy for individuals I interacted with. Communicational skills are also crucial for leaders as they help tailor the important messages correctly and build trustworthy relationships in a team (Feldman et al., 2019). My strength of encouragement is valuable for my future DNP-prepared career because I would be capable of making positive changes for my organization and community.

Leadership is also revealed in challenging situations, and stress resistance is one of the vital personal skills to develop and maintain throughout the working experience. My practice at the acute care facility revealed that I could rationally think and react in critical situations, and I consider it a strong trait worth describing in the self-assessment. The skill of managing stressful occasions is necessary for leaders not only for proper decision-making but also for giving the team an example of proper behavior (The Joint Commission, 2017). Besides, my experience in emergencies suggested that the ability to maintain calmness helps solve conflicts and decrease the overall level of aggressiveness if it takes place in a situation.

In stressful work moments, I embrace what is happening, analyze if someone needs assistance, and identify panicking people. The latter is necessary because a leader must maintain a healthy environment around the team even in critical times, and helping the anxious ones first is the right action to take (Johannessen et al., 2019). Remaining calm in a challenging situation is my leadership strength, and I always find situations to improve and teach others to develop proper responses to stress.

Although stress tolerance and the ability to encourage others can be considered sufficient skills for being a leader and accelerating my DNP-nurse career, there are still several gaps I must work on to achieve better results. Indeed, such aspect as risk management is complex for me to address because I frequently miss essential details which can severely impact my decisions. To work on decreasing the influence of that gap, I need to increase my expertise in systems development, where all the threats would be addressed in the initial stages (Feldman et al., 2019). Being a leader means minimizing risks, and I think that pre-assessment of possible problems for my team and me is necessary as I will recognize and anticipate the details.

Moreover, I experience difficulties in self-related competencies management, such as career planning and personal accountability. In the organization where I had my first nursing practice, my mentor shared their observation that I lost my initial goals and values in pursuing a result. The attitude of moving yourself to a background and prioritizing a facility’s mission or group aim is incorrect even if it seems appropriate for a leader. To fill the gap, I need to identify my own goals related to career building and work on them in a balanced manner so that they do not disrupt my leadership responsibilities (AONL, n.d.). Furthermore, having well-developed personal accountability is helpful in decision-making and priories settings, not only in the workplace but also in normal life.

Self-assessment revealed my strong and weak skills, and, based on the competencies’ analysis, I can now describe the goals to enhance my nursing leadership development. The initial aim is to improve my influencing behaviors strategies necessary to enforce my ability to encourage others. Indeed, creating effective systems and actionable plans for others combined with proper communication can help execute large groups efficiently and timely address behavioral deviations or challenges. A DNP-prepared nurse needs to be capable of analyzing and noticing the changes in the responsible group or unit’s work because, as leaders, they might need to create solutions quickly and effectively. To improve the tactics for influencing behaviors, I need to keep inspiring people around me and analyze their values and reactions to my assumptions about work, life, and career (AONL, n.d.). Developing this leadership competence is beneficial for the acute care facility I practice because, in challenging moments, I would be a reliable person capable of taking responsibility.

The second goal is to improve my risk management attitude because it is crucial for my practice as a DNP-prepared nurse and as a leader of the team where I work. I want to enhance my decision-making and strategic thinking necessary for developing appropriate strategies for optimizing work and life. Moreover, competence is crucial for identifying areas of liability at an organization, and the skill is essential for timely noticing and managing staff’s knowledge gaps (Johannessen et al., 2019). I also need to improve my systems development skill which would help me foresee the risks and correct my own aspirations and activities. Risk management attitudes development is required for all practitioners of my organization because it would enhance the overall awareness of deviations (The Joint Commission, 2017). Indeed, when each employee frequently evaluates the possibilities of threats or upcoming issues, the solutions will be found more quickly and efficiently.

The third objective for me is to explore the practical communicational approaches and identify which require closer attention. Nursing requires constant interaction with colleagues, subordinates, and patients; thus, being well-skilled at empathy, active listening, and body language understanding is beneficial for a DNP-prepared practitioner (Feldman et al., 2019). Besides, I tend to feel unconfident while speaking to over-emotional people, and addressing that issue can also be performed through communication abilities improvement. As a nurse leader, I must have enough knowledge to select the proper approach for tailoring a message or raising attention to an emerging issue. Developing the communication-related leadership competence will also support my practice in an acute care facility, as working there requires me to talk to diverse individuals.

The last goal for accelerating my leadership development is to select the literature to explore and use at work and in daily life. Indeed, reading the recent books about managing people, influence, or team building can help me find sufficient information and discover competency gaps I might be unaware of. Continuous education must go beyond the literature given by professors, and enhancing the skills through self-education is beneficial for achieving success (Johannessen et al., 2019). Implementing the current leadership strategies can support my nursing practice by sharing what I found out and encouraging my colleagues to strive for new knowledge.

Well-developed leadership skills can help DNP-prepared nurses accelerate their careers and make their work environment thrive. Consequently, competencies such as communication, high-quality care, decision-making, and the ability to take responsibility are critical for future professionals. Self-assessment helped me reveal my strengths and areas where development is required to make me a more efficient leader. Achieving the goals set based on the knowledge about my leadership capabilities will help me improve my competencies and obtain new ones.

American College of Healthcare Executives. (2017). The healthcare executive’s role in ensuring quality and patient safety [Policy statement].

American Organization for Nursing Leadership. (n.d.). AONL nurse leader competencies .

Feldman, S. S., Buchalter, S., Zink, D., Slovensky, D. J., & Hayes, L. W. (2019). Training leaders for a culture of quality and safety. Leadership in Health Services, 32 (2), 251–263.

Johannessen, T., Ree, E., Strømme, T., Aase, I., Bal, R., & Wiig, S. (2019). Designing and pilot testing of a leadership intervention to improve quality and safety in nursing homes and home care (the SAFE-LEAD intervention) . BMJ Open, 9 (6), 1–12.

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