Clinical assessment

Abstract Clinical assessment is a form of dialogue between a person and a nurse, or other healthcare professional, in which their healthcare needs are assessed, and a plan of care or clinical interventions is agreed. It is an essential interpersonal interaction which empowers people to be involved in decisions about their healthcare. For nurses, clinical assessment involves physical examination and physiological measurements, and assessment of a person’s individual psychological, sociological, and other needs, through the actions of looking, touching, listening, and measuring. Clinical assessment identifies current and predicted care needs and helps the nurse prioritize clinical interventions and care. There are a range of tools and practices available to facilitate comprehensive clinical assessments and support nurses’ clinical decision-making. There are also different types of clinical assessment, such as those when meeting a new patient or client, those carried out in a health emergency, and those which are part of everyday nursing interactions with people. This chapter describes the process of ongoing clinical assessment and outlines the range of tools available to facilitate and support nurses’ decision-making.