why is nursing assessment and care planning important
A quick guide for people using adult social care services. Why Is Caring an Important Part of Nursing? Use of accessory muscles and nose flaring was also noted. Her confidentiality was not compromised because she agreed to the presence of a family member. Implementation is the third stage of the process where clear direction is given about what is to be done, when it is to be done and by whom. This was very important because of the effects of potential panic on breathing; therefore, this was the correct balance to strike. 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. On assessment, Kate’s problem was breathing that resulted in insufficient intake of air, due to asthma. Bronchodilators are given to dilate the bronchioles constricted due to asthma, and corticosteroids reduce inflammation in the airway (BNF 2011b). Elkin, Perry and Potter (2007) outlined nursing process as a systematic way to planning and delivering care to the patient. Due to breathlessness and loss of mobility it was difficulty for Kate to maintain her personal hygiene. Through holistic assessment, therapeutic … Toward Healthy Aging: Human Needs and Nursing Response. To resolve this problem nurses use past medical history to complete the assessment. 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. Care planning is important because it guides in the on-going provision of nursing care. Newson suggests that for the process to commence a model of assessment is utilised. The nursing process provides a methodical approach to examine patient’s problems and looks at ways of resolving these problems. Carroll (2004) des… Priority setting involves ranking nursing diagnoses in order of importance. Chapter 14. 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. Barrett, Wilson and Woollands (2012a), defined a care plan as an integrated document that addresses each identified need and risk. Members of the public cannot always see the difference between a student nurse and someone who is qualified and registered with the NMC . Kate, a lady aged 84, was admitted to a medical ward through the Accident and Emergency department. The frequency of monitoring should increase if abnormal physiology is detected, as outlined in the recommendation on graded response strategy. Sense of touch should be used to feel if the patient is hot or cold or whether their skin is clammy or dry. The purpose of nursing process To identify client’s health status, actual or … 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. If a nursing care plan is in place, nurses from different shifts or different floors can utilize this information to provide the same quality and type of interventions to care for patients, thus allowing patients to receive the most benefit from treatment. No plagiarism, guaranteed! The nurse-patient relationship should be started from the initial assessment. 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). A health assessment is the collection and analysis of data in order to identify the client's problems. Secondly, the Roper, Logan and Tierney model of nursing that was used to assess the care needs of the patient will be discussed, and then the assessment process will be analysed critically. The main (primary) source would be from the patient or advocate and secondary sources would be from the patient’s relatives, patient notes or any documentation on the patient file. 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. how much fluid intake the patient has had or even how much they weigh. This is the first stage of the nursing process and therefore any issues affecting the patient can be identified. Monitoring should be more frequent if abnormal physiology is seen. How gave the information, Kate or the daughter? It focuses on the patient’s needs at that moment in time and possible needs that may need to be addressed in the future. Patient care is not just about the medical aspect of nursing. 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. The curtains were pulled around the bed, though Sibson (2010) argued that it ensures visual privacy only and not a barrier to sound. All work is written to order. 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. The purpose of nursing process. She presented with severe dyspnoea, wheezing, chest tightness and immobility. The relationship relies on specific components being in place including rapport, empathy, genuineness, warmth and positive regard. Your care plan shows what care and support will meet your care needs. This can happen even after doing exercise, not only in people with respiratory problems (Blows 2001). She has … 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). (2005) stated nursing assessments are non-static. 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. 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. 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. She takes regular bronchodilators and corticosteroids in the form of inhalers and tablets. Readings were compared with initial readings to determine changes and to report any concerns. The nurse should also introduce herself to help reduce anxiety and gain the patient’s confidence. 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?’. Nursing Link (2012) Physical Assessment: Chapter 1 History and Physical Examination. Knowing what type of a job the patient does or the type of the house she lives in helps to indicate how the patient is going to cope after discharge. 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. Under time pressure this can sometimes be neglected. 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… Nursing process is a systematic, rational method of planning and providing individualized nursing care. In contrast, a nurse job analysis in 1953 did not recognise or include care planning as a nursing task (Goddard 1953). Including student tips and advice. 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. Standard I: Assessment—The Hospice and Palliative Nurse Collects Patient and Family Health Data. 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 was seen as a problem solving approach to nursing care. important skills and experience. 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 … what do they mean, how serious are they and what is normal? However, this lower level of privacy has to be balanced against causing anxiety to the patient. Elkin, Perry and Potter (2007) outlined nursing process as a systematic way to plan and deliver care to the patient. After the baseline observations were taken, the twelve activities of living were analysed and Kate’s needs were identified. 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 model of the twelve activities of living was followed successfully on the whole. 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). 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. Identified areas of need – breathing and personal cleansing – will be discussed in relation to the care given and with reference to psychological, social, and biological factors as well as patho-physiology. This model needs to be holistic in all aspects of the patients needs. The care was always carried out according to her wishes. 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). Kate was also started on antibiotics to combat the infection because, on auscultation, the doctor found that the chest was not clear. 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. Gordon (2008) stated that understanding that any admission to hospital can be frightening for patients and allowing them some time to get used to the environment is important for nursing staff. Interviewing skills are also required and is fundamental. Are the tools user-friendly? Nurses may feel they are familiar with the concept of care planning, but true personalisation takes this to a new, more dynamic level. Holland also insisted that religion should be known in case the patient would like to have some privacy during prayers, and this should be included in the care plan. 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. St Louis, MO: Mosby. 11th Feb 2020 Firstly, the relevant life history of the patient will be briefly explained. This essay deals with the holistic assessment of a patient who was admitted onto the medical ward where I undertook my placement. 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). 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. Wilkinson (2006) explained that a goal statement is a quantifiable and noticeable criterion that can be used for evaluation. Assessment data, diagnosis, and goals are written in the patient’s care plan so that nurses as well as other health professionals caring for … Kate’s daughter thought that the bedside assessment would be more comfortable for her mother, and therefore cause least anxiety. Service evaluation is being increasingly used and led by nurses, who are well placed to evaluate service and practice delivery. 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. This is called care planning, and it’s something you’ll be involved with from day 1 of being a health care assistant. Chapelhow et al. Among the physical aspects assessed are vital signs and general observations of the patient. It acts as a guide and ensures that all areas of the assessment process are covered (Dougherty et al). 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. Registered office: Venture House, Cross Street, Arnold, Nottingham, Nottinghamshire, NG5 7PJ. Yura and walsh (1967) initialised the importance of the nursing process. 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. Care planning is an essential part of healthcare, but is often misunderstood or regarded as a waste of time. Education and training should be provided to ensure staff have these competencies, and they should be assessed to ensure they can demonstrate them. Some of the skills may become second nature to the nurse and others will be developed over time. This concept is not new, but ensures that small deviations from the norm are noticed. Record keeping and documentation skills needed to write and record information accurately and to be truthful and IT literate. Treatment and care, and the information patients are given about it, should be culturally appropriate. Personalised care and support plans . The care plan prescribed involved first gaining consent from Kate, explaining what was going to be done. Castledine (2002). Hygiene is the practice of cleanliness that is needed to maintain health, for example bathing, mouth washing and hair washing.
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