why is nursing assessment and care planning important
She was agitated and anxious. Carpenito-Moyet (2006) stated that it is important to take the first observations before any medical intervention, in order to assist in the diagnosis and to help assess the effects of treatment. Standard I: Assessment—The Hospice and Palliative Nurse Collects Patient and Family Health Data. Selecting the patients who may benefit from critical care is, therefore, crucial. Barrett, Wilson and Woollands (2012a) stated that it is very important to give psychological care to patients who are dyspnoeic because they panic and become anxious. She takes regular bronchodilators and corticosteroids in the form of inhalers and tablets. Are the tools user-friendly? Sense of hearing is required to detect if the patient has noisy breathing or whether they have slurred speech. importance of taking a person-centred and integrated approach to care planning the experience of people accessing services varies significantly (13) . Holland (2008) stated that these details should be accurate and legible so that, in case of any concerns about the patient, the next of kin can be contacted easily. Therefore, whenever Kate was being assisted with personal care, it was ensured that the screens were closed and she was properly covered. Overall the nurse must work in a professional manner and abide by the policies set out by the trust, NMC (2002) code of professional conduct and government legislation. Hemming (2010) recommended that identifying the patient’s usual habit is very important because each individual has different ideas about hygiene due to age, culture or religion. The essential requirement of accurate assessment is to view patients holistically and thus identify their real needs. It acts as a guide and ensures that all areas of the assessment process are covered (Dougherty et al). Copyright © 2003 - 2020 - NursingAnswers.net is a trading name of All Answers Ltd, a company registered in England and Wales. It consists of four stages and is cyclical in nature. The tool has had some criticism and has been suggested that it may not work. It is a relationship established solely to meet the patients needs and is therefore therapeutic in nature. In conclusion, the assessment of this patient was completed successfully, and the deviation from best practice recommendations (the lower level of privacy) was justified by the clinical circumstances. Care planning provides a "road map" of sorts, to guide all who are involved with a patient/resident's care. It is effective in involving patients in their own treatment and care and can actually serve as an intervention for patients with certain nursing diagnoses, like at risk for depressi… Assessment, planning, implementation, evaluation and review of care recording . The number of patients who can be accommodated in the intensive care and high dependency units is limited. Hess, P. (1998). There must be clear links between the assessment of need and the plan of care, its implementation, evaluation and review. Too much sympathy for a patient may result in the nurse crossing boundaries which allow the patient and nurse to engage in a therapeutic caring relationship as argued by Castledine (2004). Company Registration No: 4964706. This is extremely important as nurses because they care for people from all walks of life from rich to poor. Evaluation is the final stage and is the most important of the whole process as it informs the patient whether goals have been achieved or are being achieved. It is the Trust’s policy to do hourly observations on patients who have had one, two or three abnormal readings, until readings return to normal. Nursing activities are very important within the hospital and must solve the problems that the patient needs. Measuring skills to record accurate information from the patient i.e. Assessment: Coordinators and case managers can use client progress notes as a primary reference source when conducting a re-assessment. Care planning is an essential part of healthcare, but is often misunderstood or regarded as a waste of time. Sense of touch should be used to feel if the patient is hot or cold or whether their skin is clammy or dry. Kate indicated that she didn’t mind being assisted with washing and dressing. We want to find out not only patient’s immediate medical symptoms but also their nursing history, including their strengths, weaknesses and ways that they have adapted and coped with their life and health problems. Rather than wait for an obvious change in an individual variable the trend over time can be objectively observed. This model is extremely prevalent in the United Kingdom and it is used as a checklist on admission in order to get as much background data about the patient Holland (2008, p.9). This can be viewed as the most important step of the nursing process, as it determines the direction of care by judging how the patient is responding to and compensating for a surgical event, anesthesia, and increased physiologic demands. The gathering of information for the assessment can pose problems if the patient is suffering from an injury or illness which can affect their speech. The nurse care planning process is an important aid in the treatment of patients. Record keeping and documentation skills needed to write and record information accurately and to be truthful and IT literate. Every nurse has a professional responsibility to make sure that care plans are filled in to the best of her ability to help herself and her colleagues to continue the process of giving the best care possible necessary (Barrett, Wilson and Woollands 2012a). • Strengthening assessment and care planning: A guide for HACC assessment services in Victoria. What to expect during assessment and care planning. You'll receive a copy of the care plan and a named person to contact. Identifying usual habits helps individuals to maintain their social life if things are done according to their wishes. However, in order to provide adequate ongoing care, it’s important to have the resident’s needs assessed, so plans can be made for how those needs should be met, and to continue evaluating how effective that care has been. Your responsibilities may or may not include actually making entries to the care plan, but even if they don’t, the verbal reports you give to your registered colleagues will influence how … This is the first stage of the nursing process and therefore any issues affecting the patient can be identified. Use of accessory muscles and nose flaring was also noted. The patient will be asked questions, during the assessment process, surrounding the twelve activities and it will be established as to how the patient usual does these tasks. 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. Toward Healthy Aging: Human Needs and Nursing Response. Integrating health & social care at the point of assessment and planning means the person will not have to repeatedly share their story time and time again, as they will have one assessment & planning experience that results in a single integrated personalised care and support plan. If the total score exceeds a predefined cut-off this triggers immediate actions, including calls for experienced senior clinical advice and critical care outreach assessment. Physiological track and trigger systems should be used to monitor all adult patients in acute hospital settings. As the number of acute admissions increases, nurses are under greater pressure to prioritise care, make clinical judgements and develop their role. 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. Kate was also started on antibiotics to combat the infection because, on auscultation, the doctor found that the chest was not clear. 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. The pseudonym Kate will be used to maintain the confidentiality of the patient. The Chapelhow Framework was established around six enablers: assessment, communication, risk management, managing uncertainty, record keeping … These continue to be necessary in the Care Planning process following a comprehensive clinical assessment. (2005) stated nursing assessments are non-static. 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). Field and Smith (2008) suggested that assisting a patient with personal hygiene is the time that nurses can assess the patient holistically. Therefore, more time is needed to be sure that the necessary progress has been achieved before taking further steps. Peplau (1998) emphasises the importance of the nurse as a skilled communicator, using both verbal and non verbal levels to develop their relationship with the patient. Do you have a 2:1 degree or higher in nursing or healthcare? It should be supported by evidence-based written information tailored to the patient’s needs. These were documented hourly for early identification of any deterioration of condition; it also encouraged early identification of interventions. 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. This model needs to be holistic in all aspects of the patients needs. Privacy is very important in carrying out assessments, and this was not achieved fully in Kate’s assessment. 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). Among the needs identified, breathing and personal hygiene (cleansing), being priority needs, will be explored. Assessment data, diagnosis, and goals are written in the patient’s care plan so that nurses as well as other health professionals caring for the patient have access to it. Barrett, Wilson and Woollands (2012a), defined a care plan as an integrated document that addresses each identified need and risk. A nursing care plan provides direction on the type of nursing care the individual/family/community may need. Oxygen saturation level was also monitored with the use of a pulse oximeter. 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. However, they do not predict outcome. Under time pressure this can sometimes be neglected. Griffin and Potter (2006) stated that, respirations are normally quiet, and therefore if they are audible it indicates respiratory disease, wheezing sound indicates bronchiole constriction. It is also information that be gathered by the nurse and their perceptions at the time of the assessment. Her daughter stated that Kate has a very active social life; she enjoys going out for shopping using a shopping trolley. She has a daughter who lives one street away and visits her frequently. The nurse-patient relationship should be started from the initial assessment. The other part of the plan was to give psychological care to Kate by involving her in her care and informing her about the progress, in order to reduce anxiety. In this position, Kate was comfortable and calm while other vital signs were being checked. To collect all the relevant information different sources can be used. This is supported by Turner (2003) who, while acknowledging the benefits of technology in patient assessment, continues to highlight the importance of respiratory rate. Observations also help to detect any signs of deterioration or progress in the patient’s condition (Field and Smith 2008). St Louis, MO: Mosby. This is called care planning, and it’s something you’ll be involved with from day 1 of being a health care assistant. *You can also browse our support articles here >. Must also have the ability to refer and report information to others, ability to seek advice, establish a relationship, trust and confidentiality. After assessment, care plan is formulated. 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). She takes regular bronchodilators and corticosteroids in the form of inhalers and tablets. 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. Most assessment tools have a scoring system, the scores are added up to give an overall score. The goal statement in this case would be for Kate to maintain normal breathing, which is normally 12 – 18 breaths per minute in adults (Mallon 2010), and to increase air intake. Toward Healthy Aging: Human Needs and Nursing Response. Nursing care plans have been used for quite a number of years for human purposes and are now also getting used in the veterinary profession. Every nursing activity should produce documentation with critical thinking. Care planning is important because it guides in the on-going provision of nursing care. 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). Kate was observed for any blueness in the lips and oral mucosa as this could be a sign of cyanosis. She was also checked for any pallor, jaundice, cyanosis or dry skin that needed attention. Early warning systems rely on observations of the physiological status of the patient, reflecting a clinical evaluation of oxygen delivery and organ perfusion. In this ward the Roper, Logan and Tierney model of nursing, which is based on the twelve activities of living, is used as a base for assessing patients (Alabaster 2011). Ideally the nurse should record their findings in a non-judgemental way and consideration needs to be paid to other members of the multi-disciplinary team who may need to see the notes. During assessment, the nurse needs to use both verbal and non-verbal communication. Adult care and support should help you live your life the way you want to. She was admitted with asthma and a chest infection. Registered Data Controller No: Z1821391. Providing Consistency of Care. Why do we have them? Carers and relatives should also be given the information and support they need. Chapter 1 Developing a Care Plan . Holistic patient assessment is used in nursing to inform the nursing process and provide the foundations of patient care. The relationship relies on specific components being in place including rapport, empathy, genuineness, warmth and positive regard. This article defines evaluation of services and wider care delivery and its relevance in NHS practice and policy. We've received widespread press coverage since 2003, Your NursingAnswers.net purchase is secure and we're rated 4.4/5 on reviews.co.uk. 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. Vitals and EKG's may be delegated to certified nurses aides or nursing techs. Objective data is information that is measurable such as pulse, blood pressure, respirations and weight. Nevertheless the doctor said that 90-95% was fine for Kate, considering her condition and her age. A clear reason needs to be given as to why the approach is considered to be the most suitable. She preferred washing daily, shower and a hair wash once a week, and a mouth wash every morning and before going to bed. Castledine (2004) argues that the nurse-patient relationship is extremely important within the healthcare setting as it’s helps the patient to make informed decisions, it avoids isolation and de-humanisation, acts as an advocate for vulnerable patients, helps with the patient assessment and problem solving, helps patient undertake, or carry out for them, activities of daily living and human needs, teach and promote health education and learn about new ways of nursing and caring for people in a changing world. The student British Medicial Journal would argue that the Early Warning Score does work and recent research found that 84% of patients had documented observations of clinical deterioration within eight hours of cardiopulmonary arrest. The prescription of care for Kate depended on the assessment, which was achieved by monitoring her breathing rate, rhythm, pattern, and saturation levels. Among the physical aspects assessed are vital signs and general observations of the patient. Information was also recorded about any agency involved, along with next of kin and contact details, and details of the general practitioner. Your care plan should cover: outcomes you wish or need to achieve; what your assessed needs are Evolution of planning nursing care. Patients may experience stress about their conditions, injuries, procedures, surgeries, or recovery. Treatment and care, and the information patients are given about it, should be culturally appropriate. Before assessment takes place, the nurse should explain when and why it will be carried out; allow adequate time; attend to the needs of the patient; consider confidentiality; ensure the environment is conducive; and consider the coping patterns of the patient (Jenkins 2008). 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).
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