The Foundation of an Effective Nursing Care Plan - Essay Example

Purpose of Assessment in Adult Nursing Purpose of Assessment in Adult Nursing What is assessment? Nursing assessment is thesystematic data and information collection for the purpose of caring for the patients and their needs (Taber, 2009). It involves the identification of the needs and problems of the patients, their preferences and abilities. Assessment includes interviewing the patient, making observations and considering the signs and symptoms of the condition. The medical history of the patient is important in order to relate the condition with any genetic factors. Physical aspects of an assessment include skin colour, vital signs, sensory nerve and motor function, sleep, activity, consciousness, and elimination. Emotional and social factors on the other hand include occupation, responsibilities, family ties, attitude towards health care, emotional tone and mood (Dougherty & Lister, 2011). Nursing assessment is essential as it is the foundation of an effective nursing care plan. A comprehensive nursing assessment is conducted by a registered nurse and it can be defined as extensive and ongoing collection of data for families, individuals and communities at large. This ongoing data collection is a method of addressing emergent and anticipated changes in the health of an individual in comparison to the previous condition. Older people need continuing health care because of their interrelated health care problems. Nursing assessment for the adults is done to ensure that they get the appropriate timely and effective response to their health problems and needs (National Council of State Boards of Nursing, 2011). There is another type of nursing assessment known as the focused nursing. According to the national council of states boards of nursing (2011), this is an appraisal of the health status of an individual making a contribution to comprehensive assessment to support the ongoing data collection. Focused assessment also helps the nurses to make a decision of who needs to be given the information and when it is appropriate to do so. Focused assessment is specific on patients in emergency. Why do we carry out assessments in nursing practice? Assessment is usually the first step in the nursing process thus it is the basis for a good health care plan (Schaller-Ayers & Fuller, 2000). The crucial details for making accurate assessments are to view all patients holistically in order to identify their needs. Assessment is not just a mere collection of data but involves the critical thinking of nurses to validate and synthesize the information to make informed judgements of the life process of individuals (Standing, 2010). It is about understanding and describing the most important details of a health condition to prevent the patient from getting worse and to correct the cause of that condition. Observation ensures that the progress of the patient is continually monitored in order to detect adverse effects or delays in the recovery process (Kozier, 2002). Physical assessment helps the nurse to gather both subjective and objective data. Subjective information is based on the history of the individual and the review of the body systems, while objective data is based on physical examination. Subjective data includes pain, worrying and itching while objective data include blood pressure, skin discoloration and respiratory rate. These two forms of data are important because they help to get baseline mental and physical data on the patient; add-on, verify, or question data collected in the nursing history; acquire data that will help the nurse establish nursing diagnoses ; and appraise the suitability of the nursing interventions in resolving the patients identified problems. In the adults and other older people assessment helps to proactively manage their functional decline thus screening is highly advised. Comprehensive assessment on the other hand ensures that all potential risk areas are covered, including delirium and depression which are always under- recognized (Inouye, 2006). It is critical to ensure fast identification of risks so as to develop effective and safe pathways for managing adult’s needs. How do we carry out assessment in nursing practice? Before carrying out an assessment it is important to note that all confidentiality should be kept (Howatson, et al., 2012). However, information collected at different stages of assessment should be communicated to other relevant health professionals to ensure collaborative management of patients and their care continuity. Assessment in the cases of admission is carried out during and after admission. Admission assessment is completed by the nurse upon arrival or at least within twenty four hours of admission (Barret, et al., 2008). It involves collection of data on the history of the illness, including family and social history. This information is provided through a one on one interview with the patient. This is followed by a general assessment which includes physical, behavioural state, and emotional state. In physical assessment basic techniques used are inspection, palpation, auscultation, and percussion. Inspection is the visual examination that focuses on one area of the body at a time; palpation is the examination by touch with the intention of feeling the texture, consistency, location and size of body parts. Auscultation is examination by listening of sounds for example, abdominal and thoracic systems. This can be done directly by using the physical ears or by use of a stethoscope. Percussion involves tapping of the body by use of fingers performed by a registered nurse or a physician (Schaller-Ayers & Fuller, 2000). Behavioural and emotional states are observed through assessing body build, posture and gait, attitude and mood of the patients. Psychosocial assessment is carried out by use of a risk assessment tool known as Home, Education, Activities, Drug use and abuse, Sexual behaviour, Suicidality and depression (HEADSS). At the start of every shift in the hospital, an assessment must be completed on all patients of all the aspects mentioned. This helps to know the progress of the patient (Fontaine, et al., 2005). Assessments are carried out to get baseline information on temperature, heart rate, respiratory rate, oxygen saturation, blood pressure, weight, blood sugar level, skin, nutritional input and disability. What skills do nurses utilise to carry out assessments? Historically the role of nurses has been to record but not to interpret observations made during assessment. Recording this information accurately helps the nurse to prioritize health care. Setting priority based on assessment is a skill that all nurses should have as a way of making sound clinical decisions (Standing, 2010). To achieve this, nurses need to have a broad empirical knowledge. This is derived from sciences like physiology, sociology and philosophy from which nursing is derived. It is the underpinning knowledge of the human physiology and anatomy (Schaller-Ayers & Fuller, 2000). They also need to have tacit knowledge, which is a kind of knowledge that allows nurses to act on intuition and hunches thus engage in holistic problem solving. This is important in observing the change complications in adult patients. A broad experience for the nurses allows them to recognize similarities in event occurrence in the adult patients. They therefore understand the potential consequences of these changes and are able to act appropriately. Other important skills that a nurse requires to facilitate an assessment are psychological. A nurse with good psychological skills is able to communicate interpersonally with the patients, support them and even give counselling to encourage them. In acute care, clinical observation is essential in making judgements (Standing, 2010). The quality of the judgment is questionable depending on the skills of the nurse. It is important that nurses are trained thoroughly on the techniques and tools of assessment; the first and most important being establishment of a positive nurse patient rapport. By so doing the stress that a patient might have due to anticipation of the process is decreased. Conclusion Nurses are the first staff members that a patient sees in the hospital, it is therefore the nurses, duty to ensure that the patient gets an accurate initial assessment. By using all techniques of assessment thoroughly and considering each and every part of the body at a time, the nurse is able to give a concrete assessment. Assessments are done in order to have an idea of the underlying causes of the situation, monitor the situation to prevent any negative changes and come up with remedial measures. It is the foundation of the nursing process, and an accurate assessment leads to the correct evaluation, diagnosis, and treatment of the patient. For accurate assessment and prioritization of patients needs, having an empirical knowledge on basic physiology and anatomy and the passion to correctly make observations is essential. Reference list Barret, D., Wilson, B. & Woollands, A., 2008. Care planning :a guide for nurses. 1st ed. New York: Pearson Education. Dougherty, L. & Lister, S., 2011. The Royal Marsden Hospital of clinical nursing procedures. 8th ed. London: Wiley-Blackwell. Fontaine, K., Hudak, M. & Gallo, M., 2005. Critical care nursing: a holistic approach. Philadelphia: Lippincott Williams & Wilkins. Howatson, L., Standing, M. & Roberts, S., 2012. Patient assessment and care planning in nursing (transforming nursing practice series). 1st ed. London: Learning Matters. Inouye, S., 2006. Delirium in older persons. New England Journal of Medicine, 354(11), pp. 1158-1166. Kozier, B., 2002. Fundamentals of nursing. 6th ed. New Jersey: Addison Wesley. National Council of State Boards of Nursing, 2011. NCSBN model nursing practice Act and model nursing administrative rules. Chicago: Author. Schaller-Ayers, J. & Fuller, J., 2000. Health assessment – A nursing approach.. 3rd ed. Philadelphia: Lippincott. Standing, M., 2010. Clinical judgement and decision-making in nursing and interprofessional healthcare. London: Open University Press. Taber, T., 2009. Taber’s cyclopedic medical dictionary. 21st ed. Philadelphia: FA Davis. Read More