what do they mean, how serious are they and what is normal? A health assessment is the collection and analysis of data in order to identify the client's problems. It involves four stages: assessment, planning, implementation and evaluation. Potter and Berry (2005) argue that if inaccurate, incomplete or inappropriate data is recorded then the overall care of the patient may be affected, including wrong diagnosis and even wrong treatment. Before looking at how the Care Plan is recorded using the software, here is a quick recap of the skills and process used to develop nursing Care Plans for people living in aged residential care facilities. Priority setting involves ranking nursing diagnoses in order of importance. The nurse must learn to empathise and be must be able to listen and take in information. This gives the patient a clear picture of the care and encourages them to take part. Therefore, more time is needed to be sure that the necessary progress has been achieved before taking further steps. She was agitated and anxious. Breathing will be discussed first being an underlying problem which Kate presented with before moving on to personal cleansing. Depending on that score would depend on the care for the patient or medical intervention. The nurse must also be able to interpret the results of the measurements i.e. Copyright © 2003 - 2020 - NursingAnswers.net is a trading name of All Answers Ltd, a company registered in England and Wales. DoH (2010) articulated that consent is an essential element in all phases of care and treatment, so verbal consent was gained from the patient and the reason why the interview was being conducted was explained to the patient. Planning is a category of nursing behaviors in which client-centered goals and expected outcomes are specifically chosen to resolve the client's problem and achieve the goals and outcomes (Potter & Perry, 2005). Physiological track and trigger systems should be used to monitor all adult patients in acute hospital settings. • Strengthening assessment and care planning: A guide for HACC assessment services in Victoria. Taking and recording observations is very important because it helps to recognise the significance of changes in vital signs. The nursing process provides a methodical approach to examine patient’s problems and looks at ways of resolving these problems. Service evaluation is being increasingly used and led by nurses, who are well placed to evaluate service and practice delivery. On these grounds it is essential that the tool works to help detect early signs of deterioration in critically ill patients. The tool should complete the overall assessment process and will depend on the needs of the patient and the type of clinical setting to which tool is used as found in the work of (Brooker et al). Nurses need to familiarise themselves not just with local early warning scores system but also with local outreach services because they are there to help to make important early decisions. The chapter describes the Eshun‐Smith model to demonstrate how it has been developed as a framework for specific assessment and care planning of the older person requiring rehabilitation. Although there was a room available, Kate and her daughter said it was fine for the assessment to take place at the bedside especially that Kate was so restless. Good care planning allows healthcare professionals make evidence-based decisions about care based on a comprehensive assessment, and to prove this, if necessary (Barrett, Wilson and Woollands 2012a). The peak expiratory flow was monitored and recorded to identify the obstructive pattern of breathing that takes place in asthma (Hilton, 2005). Genuineness and trusting relationships are instrumental in reducing anxiety and helping patients to cope with pain. Chapter 4. After having medication Kate was able to participate during personal hygiene. They will often be the person who then implements the planned care and evaluates its appropriateness and success as care is delivered. Assessment is of benefit to the patient because it allows his or her medical needs to be known, but it can feel intimidating or embarrassing so the nurse needs to develop a good rapport (NursingLink 2012). In the UK the early warning scores system and the modified system trigger a call to the patient’s own team or an intensive care unit outreach team. Her daughter was with her at the bedside. Walsh (1998) described the nursing process as a tool to provide structure to . Therefore, whenever Kate was being assisted with personal care, it was ensured that the screens were closed and she was properly covered. With nasal catheter, Kate was able to communicate with the nurses and her daughter what about comfort?. Staff caring for patients in acute hospital settings should have competencies in monitoring, measurement, interpretation and prompt response to the acutely ill patient appropriate to the level of care they are providing. Record keeping and documentation skills needed to write and record information accurately and to be truthful and IT literate. The goals may be short term, for example, nil by mouth prior to surgery or long term, for example, what implementations will be in place for discharge. It’s a fair and accurate account of the individual and their life. Nurses can help to build a trusting relationship by listening to the patient, believing the patients pain experience, acting as a patient advocate and providing patients with appropriate physical and emotional support. Nursing assessment is the gathering of information about a patient's physiological, psychological, sociological, and spiritual status by a licensed Registered Nurse.Nursing assessment is the first step in the nursing process.A section of the nursing assessment may be delegated to certified nurses aides. Vitals and EKG's may be delegated to certified nurses aides or nursing techs. It is as important to be able to identify patients for whom such care will be futile to give enough time for appropriate discussions to take place with the patient and family. Available at http://nursinglink.monster.com/training/articles/298-physical-assessment—chapter-1-history-and-physical-examination, Royal College of Nursing (2010) Specialist Nurses: Changing Lives, Saving Money. In nursing, the use of language must be appropriate to the patient and be clear, free from jargon and encourage feedback. Rennie (2009) stated that subjective and objective data, as well as medical and social history are collected during patient’s interview. She was admitted with asthma and a chest infection. Observed information is information that can be gathered whilst observing the patient. This chapter explores the concept of health assessment, with particular reference to the nursing process, the use of integrated care pathways and the application of frameworks or models in the collection and organisation of assessment data. importance of taking a person-centred and integrated approach to care planning the experience of people accessing services varies significantly (13) . Her daughter stated that Kate has a very active social life; she enjoys going out for shopping using a shopping trolley. Her confidentiality was not compromised because she agreed to the presence of a family member. NMC (2008) encouraged teamwork to maintain good quality care. Physiological observations should be monitored at least every 12 hours unless a decision has been made at a senior level to increase or decrease this frequency for an individual patient. Monitoring should be more frequent if abnormal physiology is seen. immediately after assessment, namely nursing diagnosis (American Nurses Association, 2017). The normal breathing rate in a fit adult is 16-20 respirations/minute, but can go up to 30 due to pain, anxiety, pyrexia, sepsis, sleep and old age (Jenkins 2008). Free resources to assist you with your nursing studies! Part one of this paper begins with the co… Considering Kate’s age and her breathing problem, she needed multi- professional teamwork. Toward Healthy Aging: Human Needs and Nursing Response. Nursing activities are very important within the hospital and must solve the problems that the patient needs. Additionally, identifying a patient’s habits will help in care planning and setting goals. It is a relationship established solely to meet the patients needs and is therefore therapeutic in nature. Readings were compared with initial readings to determine changes and to report any concerns. Using non-verbal communication means that she should observe the patient, looking at the colour of the skin, the eyes, and taking note of odour and breathing. Resident “care plans” are an important tool used by nursing home staff to identify resident healthcare problems and the appropriate interventions to address these problems. She has … Barrett, Wilson and Woollands (2009) suggested that when enquiring about the activities of living, two elements should be addressed: usual and current routines. Under time pressure this can sometimes be neglected. All work is written to order. She presented with severe dyspnoea, wheezing, chest tightness and immobility. Any opinions, findings, conclusions or recommendations expressed in this material are those of the authors and do not necessarily reflect the views of NursingAnswers.net. A multi-disciplinary team was involved in meeting Kate’s care goals. Without a specific document delineating the plan of care, important issues are likely to be neglected. This is supported by Turner (2003) who, while acknowledging the benefits of technology in patient assessment, continues to highlight the importance of respiratory rate. The pseudonym Kate will be used to maintain the confidentiality of the patient. Kate was nursed in an upright position using pillows and a profiling bed in order to increase chest capacity and facilitate easy respiratory function by use of gravity (Brooker and Nicol, 2011). An accurate assessment enables nursing staff to prioritise a patient’s needs and to deal with the problem immediately it has been identified (Esmond 2011). Identifying usual habits helps individuals to maintain their social life if things are done according to their wishes. After assessment, care plan is formulated. Nevertheless the doctor said that 90-95% was fine for Kate, considering her condition and her age. Privacy is very important in carrying out assessments, and this was not achieved fully in Kate’s assessment. Most assessment tools have a scoring system, the scores are added up to give an overall score. Kate, a lady aged 84, was admitted to a medical ward through the Accident and Emergency department. To collect all the relevant information different sources can be used. how much fluid intake the patient has had or even how much they weigh. Personal hygiene is particularly important for the elderly because their skin becomes fragile and more prone to breaking down (Holloway and Jones 2005). Kate was observed for any blueness in the lips and oral mucosa as this could be a sign of cyanosis. Could Kate answer all the questions? This essay deals with the holistic assessment of a patient who was admitted onto the medical ward where I undertook my placement. Yura and walsh (1967) initialised the importance of the nursing process. Use of accessory muscles and nose flaring was also noted. Since Kate was immobile, it was very important to check her pressure areas for any redness. Are tools used? In a qualitative study, Carroll (2004) found broad agreement from experts about the core assessment skills that are required for nurses working in this field. Elkin, Perry and Potter (2007) outlined nursing process as a systematic way to planning and delivering care to the patient. Assessment tools are used by all healthcare practitioners. The Department of Health (2001) emphasises the importance of reducing waiting times for assessment and treatment. A nursing care plan provides direction on the type of nursing care the individual/family/community may need. Barrett, Wilson and Woollands (2012a), defined a care plan as an integrated document that addresses each identified need and risk. Kate was also started on antibiotics to combat the infection because, on auscultation, the doctor found that the chest was not clear. Kate’s initial assessment was carried out in a professional way, taking account of the patient’s particular circumstances, anxieties and wishes. The assessment form that was used during Kate’s assessment addressed personal details and the twelve activities of living. Adult care and support should help you live your life the way you want to. This gathered information provides a comprehensive description of the patient. They can utilise the information to measure how well a particular approach is meeting the individual’s stated goals. The aim of the care plan is to devise strategies that would enable the patient to overcome these barriers or problems. Care planning is important because it guides in the on-going provision of nursing care. The nursing process can be applied to all nursing settings, although the way in which it can be applied depends on patient needs and the environment at that time. Must also have the ability to refer and report information to others, ability to seek advice, establish a relationship, trust and confidentiality. How did all this affect her ability to provide you with information during the assessment? Therefore competency in holistic assessment is crucial to successful nursing care planning and maximising positive patient outcomes (Bolster & Manias 2010). This gathered information provides a comprehensive description of the patient. If you enjoyed this article, subscribe to receive more just like it. How gave the information, Kate or the daughter? Providing Consistency of Care. During physical assessment, Kate demonstrated laboured, audible breath sounds and breathlessness. A nursing care plan can help both nurses and patients identify and define realistic, achievable goals for the patient and offer a measurable marker for success and encouragement when one of these goals is met. Assessment is the first and most critical step of the nursing process, in which the nurse carries out a holistic assessment by collecting all the data about a patient in order to identify the patients nursing problems (Alfaro-Lefevre 2008). The nurse needs to adopt various skills in order for the assessment to be carried out appropriately as suggested by Barrett et al. Bronchodilators are given to dilate the bronchioles constricted due to asthma, and corticosteroids reduce inflammation in the airway (BNF 2011b). It is one in a series of articles in this supplement issue and is intended to complement these other papers by building on the definition of person-centeredness provided by Fazio, Pace, Flinner, and Kallmeyer (2018)and providing recommendations for assessments that support the practices described in the subsequent papers. Physiological observations should be monitored at least every 12 hours, unless a decision has been made at a senior level to increase or decrease this frequency for an individual patient.