Geriatric nursing assessment--the use of a standardized assessment instrument in a clinical setting

The purpose of the present study was to investigate the content and focus of nursing assessment when using a well-known Swedish, commercially available, standardized structured multidimensional instrument in the assessment of nursing needs/problems in a geriatric rehabilitation department. Two hundred and fifty-six assessment forms were quantitatively and qualitatively analysed. In 113 cases the corresponding nursing care plans were also analysed. Although a few important areas, such as communication and I-ADL, were missing, the instrument enabled the nurses to make a fairly comprehensive nursing assessment. However, the data collected with the instrument were only partly used in the nursing care plans, and relevant nursing diagnosis could be formulated in only 36 cases. The conclusions are that the data collection must be more goal-oriented and that education in diagnostic reasoning should be meaningful. To choose wide assessment areas could probably also facilitate holistic nursing care.