Nursing Assessment of Patients in the UK

By carrying out an assessment nurses can identify the causes of problems that require medical involvement. Nettina (2006)

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.

A clinical assessment is then conducted for treatment needs. Different treatment plans are made for each client. Individualized treatment plans are used to make referrals and they are updated periodically.”

“A decision made by a person (‘P’) after he has reached 18 and when he has capacity to do so, that if – (a) at a later time and in such circumstances as he may specify, a specified treatment is proposed to be carried out or continued by a person providing health care for him, and (b) at that time he lacks capacity to consent to the carrying out or continuation of the treatment, the specified treatment is not to be carried out or

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.

Those opposing the use of CTO’s are influenced by three reasons to support their position. The first reason deals with the current evidence base. For starters, international research literature has found no strong evidence on the positive or negative effects of CTO’s on three key outcomes. These outcomes are “hospital readmissions, length of hospital stay, and ‘patients’ quality of life” (Lawton-Smith et al, 2008) Furthermore, a 36-month study of 198 “patients” concluded that CTO’s do not prevent relapse and readmission of psychiatric inmates with severe and enduring “mental illnesses”. The study showed that results were in line with the current national use (Rugkasa, Yeeles, Koshiaris, & Burns, 2016). Analysis of these results shows that there is no compelling reason for CTO’s to continue to exists, given the lack of improvement that they provide.

This highlights the importance of the chosen service improvement, not only for individuals with mental health issues but for those at risk of developing mental illness and the NHS as a whole. These recommendations are present in No Health without Mental Health: A Guide for General Practice (DoH, 2012, online), The NHS Outcomes Framework 2012/13 (DoH, 2011, online), and numerous others.

In practice, there are other assessment tools such as….which I could have used but the CPA is a recommended National Standard Framework for Mental Health, introduced

The treatment planning process helps the client select the level and intensity of treatment that works best for them. When planning treatment the counsellor can consider preferences and the services available. The treatment plan may change over time but it provides a focus for ongoing support. The treatment plan comprises of two main functions, it allows for a negotiation between the client and assessor for specific interventions to address the identified problems as well as allows them to develop a

The ASPIRE framework, also referred to as the nursing process (Barratt, Wilson and Wollands, 2012) was used to structure and develop Susan’s care plan. Introduced by Barrett, Wilson and Wollands (2012), following on from APIE developed by Yura and Walsh (1967), ASPIRE stands for assessment, systematic nursing diagnosis, planning, implementation, recheck and evaluation. Hogston and Marjoram (2006) believe that systematic nursing diagnosis was added to offer direction and time for the nurse to reflect on gathered information and systematically develop a diagnosis. Also the aspect of rechecking is to enable the nurse to monitor and plot a patient’s progress contributing to the final stage of evaluation of care and if its successfulness (Barratt, Wilson and Wollands, 2012).

Assessment tools are used in the care planning process to build up a holistic picture of an individual’s needs. When all the details have been recorded an assessment can be made and suitable care and support can be identified. A few of the assessment tools are information from the individual such as diaries, observations, medical histories and checklists.

There are many forms I use to assess an individual’s needs. The first bit of the information comes from Derby City Council, which is called a outcome based support assessment. This is what they use to identify someone’s needs and how much care they require. The information on this document is great for Derby City to use, but I also need to do my own and adapt it so it’s easier for a care worker to understand as they are the ones who will be doing the care. It’s important that I read this document before going out to do my own care plan as it gives me a bit of back

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

The aim of this essay is to demonstrate the assessment process of a patient using the Roper Logan and Tierney (RLT) model of nursing framework and to show how the nursing process works alongside this model. This will be shown by a holistic history of the patient being shown, followed by how the RLT model is applicable to this patient. This is then followed by one nursing intervention being discussed showing how the nursing process is applied to patient care. The patient will be referred to as Mr Frederick Valentine to protect the patient’s anonymity as stated in the Nursing and Midwifery Council Code of Conduct (2008) guidelines.