Assessment and Care Planning for the Adult in Hospital
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- Date Submitted: 05/16/2014 02:03 PM
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Assessment and care planning for the adult in hospital
Assessment is the gathering of subjective and objective information and making judgements about a person’s health, situation, needs and wishes in order to guide further action. It is the first part of the nursing process and is essential in everyday nursing practice to enable the nurse and other health care personnel to know how to nurse a particular patient. Assessment is an ongoing central part of everyday nursing care achieved when nurses use their observation skills, critical thinking, decision-making, clinical judgement, communication and also by applying relevant theory to practice, Kennedy (1999). It should also be concerned with the patient’s quality of life, optimal functioning and promotion of independence and therefore should adopt a holistic and multidisciplinary approach, Teytelman (2002). Effective assessment ensures safety, continuity and quality of patient care while also meeting the nurse’s legal and professional obligations, Dougherty & Lister (2006). There are five main stages in assessment, namely, assessment, problem identification or diagnosis, care plan, implementation and evaluation of the care given, Kennedy (1999). During the assessment stage objective data is collected by measuring for example, blood pressure, temperature, respiratory rate, heart rate, oxygen saturation and any other relevant medical information, in order to get a baseline against which to compare the effectiveness of any care that would have been given. Subjective information in the assessment stage is based on the nurse’s ideas, feelings, beliefs and values (Heath, 2000) cited in Hinchcliff (2003) and also the patient’s perception of their abilities/disabilities, healthcare needs, resources and disease process, Dougherty & Lister (2006). The patient’s religious, spiritual, and cultural needs, emotional and psychological needs plus their social situation including impact of disease and treatment on body image...
Assessment is the gathering of subjective and objective information and making judgements about a person’s health, situation, needs and wishes in order to guide further action. It is the first part of the nursing process and is essential in everyday nursing practice to enable the nurse and other health care personnel to know how to nurse a particular patient. Assessment is an ongoing central part of everyday nursing care achieved when nurses use their observation skills, critical thinking, decision-making, clinical judgement, communication and also by applying relevant theory to practice, Kennedy (1999). It should also be concerned with the patient’s quality of life, optimal functioning and promotion of independence and therefore should adopt a holistic and multidisciplinary approach, Teytelman (2002). Effective assessment ensures safety, continuity and quality of patient care while also meeting the nurse’s legal and professional obligations, Dougherty & Lister (2006). There are five main stages in assessment, namely, assessment, problem identification or diagnosis, care plan, implementation and evaluation of the care given, Kennedy (1999). During the assessment stage objective data is collected by measuring for example, blood pressure, temperature, respiratory rate, heart rate, oxygen saturation and any other relevant medical information, in order to get a baseline against which to compare the effectiveness of any care that would have been given. Subjective information in the assessment stage is based on the nurse’s ideas, feelings, beliefs and values (Heath, 2000) cited in Hinchcliff (2003) and also the patient’s perception of their abilities/disabilities, healthcare needs, resources and disease process, Dougherty & Lister (2006). The patient’s religious, spiritual, and cultural needs, emotional and psychological needs plus their social situation including impact of disease and treatment on body image...