VALORACION ENFERMERIA. APK

Nursing Assessment

Overview

• A nursing assessment involves a comprehensive evaluation of the patient’s condition, needs, and risks, using standardized tools to ensure objectivity and accuracy.

• It helps guide clinical decision‑making and care planning.

Neurological Evaluation

• Glasgow Coma Scale (GCS):

+ Used to assess a patient’s level of consciousness by evaluating eye opening, verbal response, and motor response.

- Eye opening: Spontaneous, to speech, to pain, or none.

- Verbal response: Oriented, confused, inappropriate words, incomprehensible sounds, or none.

- Motor response: Obeys commands, localizes pain, withdraws from pain, abnormal flexion, abnormal extension, or none.

Risk of Pressure Ulcers

• Norton Scale:

+ Evaluates physical condition, mental state, activity level, mobility, and incontinence to determine the patient’s risk of developing pressure injuries.

Functional Independence

• Barthel Index:

+ Measures performance in activities of daily living (ADLs), such as feeding, bathing, dressing, bowel and bladder control, transfers, mobility, and climbing stairs.

+ Provides a score indicating the degree of independence or need for assistance.

Cognitive Function

• Pfeiffer Short Portable Mental Status Questionnaire (SPMSQ):

+ Assesses orientation, memory, and calculation abilities to detect possible cognitive impairment.

Nutritional Assessment

• Body Mass Index (BMI):

+ Calculated from weight and height to classify nutritional status (underweight, normal weight, overweight, or obesity).

+ Important for detecting malnutrition or excess weight, both of which can affect recovery.

Obstetric Considerations

• Probable Delivery Date:

+ Estimated based on the date of the last menstrual period or early ultrasound findings.

+ Guides prenatal care planning and monitoring.

Additional Observations

• Vital signs, pain assessment, mobility evaluation, and any other relevant health indicators.

• Social and emotional factors impacting health and recovery.

• This structured approach ensures that patient care is based on measurable data, reducing risks and improving outcomes.

FAQ

Q: Why are standardized assessment tools so important in nursing assessments?

A: Standardized tools promote consistency, reliability, and objectivity in data collection. When nurses use validated instruments—such as the Glasgow Coma Scale for consciousness or the Barthel Index for daily living activities—they reduce personal bias, improve communication among care team members, and create a common language to track changes over time. This improves patient safety, facilitates evidence-based interventions, and ensures that care remains focused on measurable outcomes.

Q: How is the Glasgow Coma Scale (GCS) used to evaluate neurological status?

A: The Glasgow Coma Scale assesses three key responses: eye opening, verbal output, and motor reaction. By scoring each domain—from spontaneous eye opening down to no response, or from oriented conversation down to no verbal output—nurses obtain a total score that ranges from 3 (deep coma or death) to 15 (fully alert). Regular GCS measurements help detect early deterioration or improvement in neurological function, guiding timely interventions such as airway management or neuroimaging.

Q: What does a change in the GCS score signify, and when should I escalate care?

A: A drop of two or more points in the Glasgow Coma Scale is clinically significant and often signals worsening intracranial pressure, cerebral hypoxia, or other neurologic emergencies. If a patient’s score falls below eight, airway protection becomes a priority because of the high risk of compromised breathing and loss of protective reflexes. Such changes require immediate notification of the medical team and possible transfer to a higher level of care.

Version History

v9.8——29 Dec 2025

Get the Glasgow Coma Scale, Norton, Barthel, Pfeiffer. BMI, birth date. Download the latest version of VALORACION ENFERMERIA. to enjoy new features and updates immediately!

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