Nursing Assessment

Mrs Gale is a 70 year old widow and retired unskilled worker. The patient lives alone and relies on her son to provide basic care,

In this Assessment nursing course, one of the major things that is taught is the most important part of giving proper care to a patient. Correct patient assessment is needed before any nursing care plan or treatment can be implemented. This post-review of a person’s assessment will demonstrate the proper way to go about assessing a person’s health.

The first stage of the process is assessment. Roper et al (2001) refer to this process as ‘assessing’ indicating an ongoing activity; this encourages nurses to recognise the on-going nature of this initial phase. The assessing stage includes gathering information about a patient, reviewing this information, identifying actual and potential problems and prioritising (Roper et al 2001). Roper et al (2001) explain the importance for assessing, as early as possible in the patient’s stay. Extensive, in-depth information may not be gathered on an initial assessment, however any information obtained contributes towards individualised care (Roper et al 2001). Ambrose and Wittig (1998) explain that the initial assessment becomes a foundation for ongoing assessing and holistic care. Barrett, Wilson and Woollands (2009) concord with Roper et al and Wittig in that assessing is an ongoing process and elaborate on this explaining that assessment should not be confused with admission. They state “an admission tends to be a one-off process when you first meet the patient, whereas assessment carries on throughout your relationship with the patient” (pg22). Assessment enables the nurse and patient to identify actual and potential problems. Although, some problems can be directly related to biological needs, holistic needs must be considered, i.e. psychological state and cultural/social standing

A is an 87 year old women, with a long history of health troubles including chronic kidney disease, congestive heart failure, coronary artery disease, a pacemaker insertion for her atrial fibrillation, type 2 diabetes, dyslipidemia, colon cancer, breast cancer, mild cognitive impairment and most recently paranoid psychosis.

During my assessment, I encountered many medical conditions my patient has that supports that she is having problems with a few of the geriatric syndromes. When it comes to sleep, my patient does not seem to sleep very well and has difficulty falling asleep. There are no signs that my resident has any problems with her everyday feeding and eating. She is able to perform this daily activity individually. As for having trouble with incontinence, for the most part this resident is able to tell a caregiver when she has to use the restroom. To make herself more comfortable at night she will not eat or drink anything too late which prevents her from having to use the bathroom during sleep hours. While she will not ask for help, if the need arises, she will use a bed pan. However, on rare occasions the patient may have an accident while sleeping because there was no feeling that she had to

Nursing process is a systematic process that involves a continuous cycle of five interrelated phases: holistic assessment of a client, nursing diagnoses, nursing care planning, implementation, and evaluation (Wilkinson et al. 2015). It enables nurses to assess the person’s health status and health care needs, to create plans to meet the identified needs, and to provide and evaluate individualised nursing interventions according to the person’s needs (Luxford 2015). The holistic assessment is the first step of the nursing process that includes the collection of subjective and objective data related to the physical, psychological, social, developmental, cultural, and spiritual status of a client (Wilkinson et al. 2015). This comprehensive approach to nursing assessment is essential because it allows nurses to comprehend not only clients’ health status, but also their routines and needs in order to incorporate their life-styles into the care interventions (Luxford 2015). It ultimately enables nurses to provide appropriate quality person-centred care rather than nurse-initiated care (Luxford 2015). Responsibility for holistic nursing assessment is supported by the Registered nurse standards for practice (2016), ‘Standard 4.1: The registered nurse conducts assessments that are holistic as well as culturally appropriate’ (Nursing and Midwifery Board of Australia [NMBA] 2016, p. 4). This essay will discuss the elements and the importance of holistic assessment in nursing.

This piece of work will be based on the pre-assessment process that patients go through on arrival to an endoscopy unit in which I was placed in during my second year studying Adult diploma Nursing. I will explore one patient’s holistic needs, identifying the priorities of care that the patient requires; I will then highlight a particular priority and give a rational behind this. During an admission I completed under the supervision of my mentor I was pre-assessing a 37 year old lady who had arrived to the unit for an upper gastrointestinal endoscopy. During the pre-assessment it was important that a holistic assessment is performed as every patient is an individual with unique care needs as the patient outline in this piece of work has

The national league for nurses defines critical thinking in the nursing process as “a discipline specific, reflective reasoning process that guides a nurse in generating, implementing, and evaluating approaches for dealing with client care and professional concerns” (Kozier, 2008). This definition is imperative to help a nursing student learn how to think in terms of nursing care. Nursing students must achieve a comprehensive understanding of critical thinking in order to understand the nursing process. The purpose for this paper is for nursing students to learn how to use the nursing process, how to properly document their findings and assessments, and correctly implement APA formatting in a formal paper.

The assessment process is the back bone to any package of care and it is vital that it is personal and appropriate to the individual concerned. Although studies have found that there is no singular theory or understanding as to what the purpose of assessment is, there are different approaches and forms of assessment carried out in health and social care. These different approaches can sometimes result in different outcomes.

Assessment is the accurate collection of comprehensive data pertinent to the patient’s health or the situation (“American Nurses Association,” 2010). Assessment is the first step in the nursing process and the most important. Assessment is the accurate collection of the patient’s health date

Generally, an assessment in nursing involves an evaluation of an individual’s health. It is a key component of nursing practice. It involves collecting and analyzing data in order to plan patient-centered care (Wilson & Giddens, 2014, 1). Assessment is the foundation of the nursing process, involving the collection of subjective and objective data (Weber & Kelley, 2013, 3). Given its nature of importance in nursing practice, nurses should always ensure that they conduct in-depth

Assessment in the nursing process will establish the patients' ongoing needs and provide a quality of care best suited to the individual, to achieve a desirable health outcome.

Assessment in nursing has been determined by the problem-solving framework of the nursing process and nursing models. It is a dynamic and continuous process as clients needs change; it promotes individualized care and responds to clients in a responsible and timely manner to improve or maintain their level of health (RCN, 2004). A health assessment not only comprises of gathering health information about a patient, but also analyzing and synthesizing the information, and evaluating the effectiveness of nursing interventions on patients health care outcomes (Weber & Kelley, 2013).

High-quality nursing is a right way to patient’s correct diagnostics, treatment and recovery. The role of a patient’s assessment is one of basic steps in the process of a patient’s care and treatment. Subjective and objective assessment skills define in the process of interaction of a nurse with a patient. According to one of recent studies, “Nurses are responsible for comprehensive health assessment of patients, and now more than ever, expected to provide timely assessment and deliver high quality care in hospital environments” (Penney, Poulter, Cole, & Wellard, 2016). There is a need for modern nurses to apply a wide range of assessment skills, which depend on the educational background of a nurse.

It is important that the four stages of the process from assessment to evaluation are carried out sequentially because each phase follows logically from one to the other. As a result the maximum well-being of the patient is always the key issue and the nurse is aware and confident of action to be taken during intervention. This essay will describe the nursing process and the importance each of the