Introduction
Assessment and nursing actions are two essential components of nursing care. Assessment involves the collection and interpretation of data about the client’s health status. Nursing actions are interventions that nurses take to promote, maintain, or restore the client’s health.
Assessment Cues
Assessment cues are observable or measurable data that can be used to assess the client’s health status. Assessment cues can be obtained from a variety of sources, including:
- The client’s medical history
- Physical examination
- Laboratory and diagnostic tests
- Observation of the client’s behavior and appearance
- Client reports of symptoms and concerns
Anticipated Nursing Actions
Anticipated nursing actions are the interventions that the nurse expects to take based on the client’s assessment cues. Anticipated nursing actions should be based on the client’s individual needs and goals, as well as on evidence-based practice.
Examples of Assessment Cues and Anticipated Nursing Actions
The following table provides examples of assessment cues and anticipated nursing actions for a client with a diagnosis of pneumonia:
| Assessment Cue | Anticipated Nursing Action | |—|—|—| | Increased respiratory rate | Monitor respiratory rate and rhythm. Assess for signs of respiratory distress, such as shortness of breath, use of accessory muscles, and cyanosis. | | Productive cough | Assess the characteristics of the cough, such as color, consistency, and amount of sputum. Obtain a sputum sample for culture and sensitivity testing. | | Fever | Monitor temperature. Provide antipyretics and cooling measures as needed. | | Decreased oxygen saturation | Administer oxygen therapy as prescribed. Monitor oxygen saturation levels closely. | | Chest pain | Assess the characteristics of the chest pain, such as location, intensity, and duration. Perform a cardiac assessment. |
Conclusion
Assessment and nursing actions are two essential components of nursing care. By carefully assessing the client’s health status and taking appropriate nursing actions, nurses can help to promote, maintain, or restore the client’s health.
Additional Considerations
In addition to the specific assessment cues and anticipated nursing actions listed above, nurses should also consider the following when assessing and caring for clients:
- The client’s overall health status and comorbidities
- The client’s age and developmental stage
- The client’s cultural background and beliefs
- The client’s individual needs and goals
- The client’s environment
By considering all of these factors, nurses can provide the best possible care for their clients.
