Definition
Assessment is the systematic collection of key information to inform care. Monitoring is the regular updating of this information. Assessment and monitoring are iterative processes.
Accurate assessment and ongoing monitoring of a patient’s physical and mental health are critical to the provision of effective, safe and timely care and the plotting of progress/deterioration. Assessment and monitoring of the patient’s relatives’ responses to the illness/condition and its consequences also need to be conducted. All nurses, regardless of the healthcare setting in which they work, undertake various types of assessment and monitoring.
Skilled assessment is linked to the ability to prioritise care that needs to be done urgently (e.g. through using early‐warning scales) and care that can wait.
Successful assessment and monitoring involve nurses merging hard data (e.g. from measurement equipment and assessment scales) with soft data (e.g. from talking, watching and listening to patients, their families and their healthcare team members) to form a complete picture of the patient’s condition and their response(s) to it and to nursing care and treatments.
Assessments can range from the comprehensive (e.g. covering physical, psychological, social, emotional, spiritual and cultural dimensions) to the specific (e.g. taking a temperature or monitoring wound healing).
Making a comprehensive nursing assessment should be done in partnership with the patient and their family/carers and it underpins the delivery of care. All nursing assessments should inform and be informed by those made by other health and social care workers.
The specific assessment and monitoring of elements of a patient’s health can help in the early detection of general health problems (e.g. hypertension); in establishing the effectiveness of treatments (e.g. in type 1 diabetes); in determining the progression of an acute illness (e.g. an infection) or a long‐term condition (e.g. multiple sclerosis), the impact of one type of illness on another (e.g. an acute respiratory infection on asthma) and the generation of one illness because of another (e.g. depression resulting from chronic obstructive pulmonary disease).
Accurate baseline assessments are essential if improvement or deterioration of a patient’s health is to be identified swiftly and managed appropriately through ongoing monitoring.
The results of assessment and monitoring need to be accurately recorded in a patient’s care plan or notes.
Initial assessments and deviations from the expected course of a patient’s condition need to be effectively communicated to relevant healthcare team members. Using a structured approach to communicating your assessment and planning (e.g. SBAR: Situation, Background, Assessment and Recommendation) can be useful in effectively explaining requirements to patients, their families and members of the multi‐disciplinary team.
Following an initial nursing assessment, the majority of ongoing monitoring is likely to focus on four key areas:
- The patient’s physical health and present condition set against the treatment plan.
- The patient’s mental health and present condition set against the treatment plan.
- Any special requirements the patient has.
- The patient’s and the carer’s requirements for social support.
