why is nursing assessment and care planning important

The nursing process provides a methodical approach to examine patient’s problems and looks at ways of resolving these problems. London: RCN. A nursing care plan provides direction on the type of nursing care the individual/family/community may need. Registered Data Controller No: Z1821391. It has been said that nurses should be able to use their nursing intuition to assess whether a patient is deteriorating. Available at http://www.rcn.org.uk/__data/assets/pdf_file/0008/302489/003581.pdf, Category: Essay & Dissertation Samples, Health Essay Examples. This can jeopardise patient care. Care plans also help in assigning the correct and most qualified staff to provide the care outlined in the plan. Rennie (2009) stated that subjective and objective data, as well as medical and social history are collected during patient’s interview. In 1978, the planning of nursing care was becoming a common topic for discussion in the nursing profession (Clarke 1978). Among the physical aspects assessed are vital signs and general observations of the patient. The model of the twelve activities of living was followed successfully on the whole. 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. Furthermore, the role of inter-professional skills in relation to care planning and delivery will be analysed, and finally the care given to the patient will be evaluated. how much fluid intake the patient has had or even how much they weigh. At this stage some problems may be noted and so the cycle must start again with assessment. Even though the initial assessment and planning will often be performed by a nurse, the support worker will be involved in all aspects. 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 nurse must also be able to interpret the results of the measurements i.e. The prescription of care for Kate depended on the assessment, which was achieved by monitoring her breathing rate, rhythm, pattern, and saturation levels. She presented with severe dyspnoea, wheezing, chest tightness and immobility. The name and age are also vital in order to correctly identify the patient to avoid mistakes. Field and Smith (2008) suggested that assisting a patient with personal hygiene is the time that nurses can assess the patient holistically. In this position, Kate was comfortable and calm while other vital signs were being checked. Pulse rate and temperature were also being checked and recorded because if raised, they indicate infection in the blood. This is called care planning, and it’s something you’ll be involved with from day 1 of being a health care assistant. Breathing will be discussed first being an underlying problem which Kate presented with before moving on to personal cleansing. important skills and experience. After having medication Kate was able to participate during personal hygiene. 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. Why do we have them? Walsh (1998) described the nursing process as a tool to provide structure to . 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). The aim of the care plan is to devise strategies that would enable the patient to overcome these barriers or problems. Personal details such as name, age, address, nickname, religion, and housing status were recorded. Information was also recorded about any agency involved, along with next of kin and contact details, and details of the general practitioner. Carers and relatives should also be given the information and support they need. Assessment can also take a long time, especially with the elderly who are usually slow to respond. What are they for? Though Hemming said all human beings need personal hygiene, Holland (2008) argued that it is important to ask patients how they feel about being cleaned, especially genital area. 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. Under time pressure this can sometimes be neglected. St Louis, MO: Mosby. Without a specific document delineating the plan of care, important issues are likely to be neglected. 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. This is extremely important as nurses because they care for people from all walks of life from rich to poor. Check your syntax! Mallon (2010) stated that, if the breathing rate is more than 20, it indicates that the body is trying to increase its intake of oxygen to meet unusual demands. 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. This was very important because of the effects of potential panic on breathing; therefore, this was the correct balance to strike. She takes regular bronchodilators and corticosteroids in the form of inhalers and tablets. To establish plans to meet the identified needs and … However, poor staffing also affects performance in this area, an observation supported by the Royal College of Nursing (2012). The nurse collected subjective and objective data, allowing a nursing diagnosis to be formulated, goals to be identified and a care plan to be constructed and implemented. That is why a student’s conduct is important in upholding the reputation of the professions, both when studying and in personal life. Barrett, Wilson and Woollands (2009) suggested that when enquiring about the activities of living, two elements should be addressed: usual and current routines. Subjective data is descriptive information that forms an opinion and is the sort of information that can be gained by asking someone ‘How do they feel?’ or ‘What is worrying you?’. Therefore, more time is needed to be sure that the necessary progress has been achieved before taking further steps. The planning stage of the nursing process will require the nurse to use decision-making and problem-solving skills in designing a plan of care for each patient. 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. Ebersole, P and Hess, P. (1998). 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. 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. As Kate was an adult and was judged by the nurses present to understand what she was consenting to, it was acceptable for her to consent to having her daughter present (Ebersole and Hess 1998). Her daughter stated that Kate has a very active social life; she enjoys going out for shopping using a shopping trolley. With nasal catheter, Kate was able to communicate with the nurses and her daughter what about comfort?. Are tools used? Interviewing skills are also required and is fundamental. Kate was on oxygen since admission; therefore she was taught about importance of healthy breathing and taught her about breathing exercises to help her wean from oxygen. (CAIPE 2010), An appropriate environment needs to be established to ensure privacy, dignity and patient comfort. Kate was able to wash and dress herself with minimal assistance. Both Kate and her daughter were asked if it was okay for her daughter to be around while assessment was carried out, so that she could help with some information, to which both agreed. Genuineness and trusting relationships are instrumental in reducing anxiety and helping patients to cope with pain. Generally, the rules that govern record-keeping and confidentiality and consent also apply to care planning. The frequency of monitoring should increase if abnormal physiology is detected, as outlined in the recommendation on graded response strategy. 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 practice guide was developed by the Victorian Department of Health and it describes the skills, techniques and knowledge base required to deliver Living at Home Assessments for people in the HACC target group. 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. 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. immediately after assessment, namely nursing diagnosis (American Nurses Association, 2017). This is a good example of the use of inter-professional skills, as a number of different departments were involved in creating and implementing the care plan. It’s a fair and accurate account of the individual and their life. ” Assessment is the first stage of the nursing process, in which data about the patients health status is collected and from which a nursing care plan can be devised” (Oxford dictionary for Nurses 2008). The nurse care planning process is an important aid in the treatment of patients. 6 1.2 Aim To explore the process of care planning/shared decision making and describe the experiences of patients and healthcare professionals in order to determine factors that influence successful development of a care plan. No information regarding the hospital or ward will be mentioned, in accordance with the Data Protection Act 1998. Kate’s initial assessment was carried out in a professional way, taking account of the patient’s particular circumstances, anxieties and wishes. Kenworthy et al (2002) writes that positive regard refers to the idea that there should be no conditions to acceptance and care for the people. The call bell was always in reach for to call when in need. She was discharged on a continuous care package comprising care three times a day, although discharge was delayed by one week so that the care package could be ready. The importance of h olistic However, the system was not as efficient as it should have been: Kate spent unnecessary time in hospital after recovery because the care plan was not yet in place. Vitals and EKG's may be delegated to certified nurses aides or nursing techs. This gives the patient a clear picture of the care and encourages them to take part. The nurse-patient relationship is based on the patient’s need for care, assistance and guidance. Through holistic assessment, therapeutic … How did all this affect her ability to provide you with information during the assessment? All the prescribed nebulisers, inhalers, bronchodilators, corticosteroids, antibiotics and oxygen therapy were administered according to the doctor’s instructions. Personal hygiene is particularly important for the elderly because their skin becomes fragile and more prone to breaking down (Holloway and Jones 2005). The aim of outreach teams is to monitor and help in the management of acute patients and provide support and advice about critical care. During assessment, the nurse needs to use both verbal and non-verbal communication. Care planning is an essential part of healthcare, but is often misunderstood or regarded as a waste of time. Throughout this assignment, confidentiality will be maintained to a high standard by following the Nursing and Midwifery Council (NMC), Code of Conduct (2008). If the patient agrees, carers and relatives should have the opportunity to be involved in decisions about treatment and care. Since Kate was immobile, it was very important to check her pressure areas for any redness. Every nursing activity should produce documentation with critical thinking. However, the one flaw in this process was delays, caused partly by the difficulties of working across different departments, and partly, it seems, by staff shortages. Carroll (2004) des… A clear reason needs to be given as to why the approach is considered to be the most suitable. On assessment, Kate’s problem was breathing that resulted in insufficient intake of air, due to asthma. Castledine (2002). Documentation is also very important in this process; all information collected has to be recorded either in the patient’s file or electronically (NMC, 2009b). Evaluation of service delivery is an important aspect of nursing practice. This article aims to enhance nurses’ understanding of nursing care plans, reflecting on the past, present and future use of care planning. Nevertheless the doctor said that 90-95% was fine for Kate, considering her condition and her age. Copyright © 2003 - 2020 - NursingAnswers.net is a trading name of All Answers Ltd, a company registered in England and Wales. Did the daughter know the answer to all the questions? It was seen as a problem solving approach to nursing care. Are the tools user-friendly? The number of patients who can be accommodated in the intensive care and high dependency units is limited. This is the first stage of the nursing process and therefore any issues affecting the patient can be identified. Record keeping and documentation skills needed to write and record information accurately and to be truthful and IT literate. Preparation and planning of the assessment was made before the interview to encourage future progress of a working relationship. Service evaluation is being increasingly used and led by nurses, who are well placed to evaluate service and practice delivery. Part one of this paper begins with the co… 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. This essay deals with the holistic assessment of a patient who was admitted onto the medical ward where I undertook my placement. If nursing documents are not clear and accurate, inter-professional communication and an evaluation of nursing care cannot be optimal. Patient care is not just about the medical aspect of nursing. She was also checked for any pallor, jaundice, cyanosis or dry skin that needed attention. The tool has had some criticism and has been suggested that it may not work. Assessment is extremely important because it provides the scientific basis for a complete nursing care plan (Wilkinson 2006). This involves consideration of the central theories of nursing and discussion of nursing models and the nursing process. Jump to: Making decisions ; Your needs assessment ; Care and support plan ; Further information . This paper provides practice-oriented guidelines for person-centered assessment of persons living with dementia, their family members, and care partners. 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. Wilkinson (2006) states that a nursing diagnosis is an account about the patient’s current health situation. Additionally, identifying a patient’s habits will help in care planning and setting goals. Assessment is the first stage of the nursing process and enables the nurse to undertake a holistic assessment of the patient considering all of the individuals needs in order to identify their problems. Did this affect the way the questions were asked? The first was developed in Australia, and several other systems have since been developed around the world, incorporating many physiological variables and trigger algorithms. Treatment and care, and the information patients are given about it, should be culturally appropriate. 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. The care was always carried out according to her wishes. This can … A bewildering array of methods to quantify the severity illness are available. As found in the work of Barrett et al assessment is a procedure in which the nurse will need to gather information from questions that are asked during the assessment process and on-going observations. The Department of Health (2001) emphasises the importance of reducing waiting times for assessment and treatment. Kate is a patient known to suffer from chronic chest infections and asthma, with which she was diagnosed when she was young. Personalised care and support plans . Monitoring should be more frequent if abnormal physiology is seen. 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). Evolution of planning nursing care. This gathered information provides a comprehensive description of the patient. what do they mean, how serious are they and what is normal? Why Is Caring an Important Part of Nursing? 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. Her confidentiality was not compromised because she agreed to the presence of a family member. As found in the work of Barrett et al assessment is a procedure in which the nurse will need to gather information from questions that are asked during the assessment process and on-going observations. In nursing, the use of language must be appropriate to the patient and be clear, free from jargon and encourage feedback. The nurse-patient relationship should be started from the initial assessment. The normal saturation level is 95-99% (British National Formulary ((BNF)) 2011a). 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. Progress from assessment to care goals was good, and at this point an inter-disciplinary team was used successfully. 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). Use of accessory muscles and nose flaring was also noted. The peak expiratory flow was monitored and recorded to identify the obstructive pattern of breathing that takes place in asthma (Hilton, 2005). Priority setting involves ranking nursing diagnoses in order of importance. This is another method that is used to assess the effectiveness of the medication (inhalers) the asthmatic patient is taking, and this test should be carried out 20 minutes after medication has been absorbed. The aim of the tool is to help pick out certain information which may not have been picked up during initial observations of the patient. Your care plan should cover: outcomes you wish or need to achieve; what your assessed needs are Some of the skills may become second nature to the nurse and others will be developed over time. Field and Smith (2008) stated that personal cleansing also stimulates the body, produces a sense of well-being, and enables nurses to assess the patient holistically. 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. Notes may also indicate improvement or deterioration of the individual and prompt changes in service delivery or identify needed referrals. VAT Registration No: 842417633. Checking and recording of breathing rate and pattern is very important because it is the only good way to assess whether this patient is improving or deteriorating, and it can be a very helpful method for nurses to evaluate the care of the patient (Jamieson 2007). The curtains were pulled around the bed, though Sibson (2010) argued that it ensures visual privacy only and not a barrier to sound. The goal for meeting this need was to maintain personal hygiene and comfort. 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). regarding that which is relevant and important (Barrett et al 2012). The Chapelhow Framework was established around six enablers: assessment, communication, risk management, managing uncertainty, record keeping … Barrett, Wilson and Woollands (2012a), defined a care plan as an integrated document that addresses each identified need and risk. 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. (ID: 2), Assessment and Care Planning Essay - commompapers.org, The Impact of Trading Volumes on Stock Market Volatility and Returns: A Case of the Swiss Stock Market, Emergence Of Artificial Intelligence In Writing Industry. 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). To identify client’s health status, actual or potential healthcare problems or need. 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.

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