Kate lives on her own in a one bedroom flat. importance of taking a person-centred and integrated approach to care planning the experience of people accessing services varies significantly (13) . Under time pressure this can sometimes be neglected. Toward Healthy Aging: Human Needs and Nursing Response. Therefore, more time is needed to be sure that the necessary progress has been achieved before taking further steps. She takes regular bronchodilators and corticosteroids in the form of inhalers and tablets. Standard I: Assessment—The Hospice and Palliative Nurse Collects Patient and Family Health Data. It acts as a guide and ensures that all areas of the assessment process are covered (Dougherty et al). 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. To export a reference to this article please select a referencing stye below: If you are the original writer of this essay and no longer wish to have your work published on the UKDiss.com website then please: Our academic writing and marking services can help you! This is due to slower epidermal cell renewal and a reduction in collagen (Hess 1998). Record keeping and documentation skills needed to write and record information accurately and to be truthful and IT literate. Care plans can be problematic when they are not filled in correctly or are completed carelessly. All work is written to order. Early warning systems rely on observations of the physiological status of the patient, reflecting a clinical evaluation of oxygen delivery and organ perfusion. Sense of touch should be used to feel if the patient is hot or cold or whether their skin is clammy or dry. how much fluid intake the patient has had or even how much they weigh. 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. 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. 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. Selecting the patients who may benefit from critical care is, therefore, crucial. Walsh (1998) described the nursing process as a tool to provide structure to . 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. 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. There must be clear links between the assessment of need and the plan of care, its implementation, evaluation and review. 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. (Barett et al 2009). Privacy is very important in carrying out assessments, and this was not achieved fully in Kate’s assessment. This model needs to be holistic in all aspects of the patients needs. Evaluation of service delivery is an important aspect of nursing practice. 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). In the UK the early warning scores system and the modified system trigger a call to the patient’s own team or an intensive care unit outreach team. 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. 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. The Nursing and Midwifery Council (2002) recognises the importance of the nurse-patient relationship in the code of professional conduct. Early warning scoring systems aim to predict which patients are in need, allow preventive management, and determine who might need a step up to higher levels of care. The essential requirement of accurate assessment is to view patients holistically and thus identify their real needs. The goal for meeting this need was to maintain personal hygiene and comfort. Nurses may feel they are familiar with the concept of care planning, but true personalisation takes this to a new, more dynamic level. Wilkinson (2006) states that a nursing diagnosis is an account about the patient’s current health situation. The call bell was always in reach for to call when in need. It also enables the response to primary interventions to be monitored. She takes regular bronchodilators and corticosteroids in the form of inhalers and tablets. Free resources to assist you with your nursing studies! This is supported by Turner (2003) who, while acknowledging the benefits of technology in patient assessment, continues to highlight the importance of respiratory rate. During physical assessment, Kate demonstrated laboured, audible breath sounds and breathlessness. Objective data is information that is measurable such as pulse, blood pressure, respirations and weight. 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… 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). Assessment: Coordinators and case managers can use client progress notes as a primary reference source when conducting a re-assessment. 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). Members of the public cannot always see the difference between a student nurse and someone who is qualified and registered with the NMC . In a qualitative study, Carroll (2004) found broad agreement from experts about the core assessment skills that are required for nurses working in this field. what do they mean, how serious are they and what is normal? The normal saturation level is 95-99% (British National Formulary ((BNF)) 2011a). Care plans also help in assigning the correct and most qualified staff to provide the care outlined in the plan. Kate was allocated a bed within a four-bed female bay. 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). How gave the information, Kate or the daughter? 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. 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. In 1978, the planning of nursing care was becoming a common topic for discussion in the nursing profession (Clarke 1978). 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. Generally, the rules that govern record-keeping and confidentiality and consent also apply to care planning. This concept is not new, but ensures that small deviations from the norm are noticed. It should also be accessible to people with additional needs such as physical, sensory or learning disabilities, and to people who do not speak or read English. Elkin, Perry and Potter (2007) outlined nursing process as a systematic way to planning and delivering care to the patient. 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. This is logical because it reflects not only respiratory function but cardiovascular upset for example, pulmonary oedema and metabolic imbalance as seen in diabetic ketoacidosis. 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). St Louis, MO: Mosby. This can happen even after doing exercise, not only in people with respiratory problems (Blows 2001). 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). She was also checked for any pallor, jaundice, cyanosis or dry skin that needed attention. DoH (2010) articulated that consent is an essential element in all phases of care and treatment, so verbal consent was gained from the patient and the reason why the interview was being conducted was explained to the patient. London: RCN. Hess, P. (1998). Holistic patient assessment is used in nursing to inform the nursing process and provide the foundations of patient care. The aim of outreach teams is to monitor and help in the management of acute patients and provide support and advice about critical care. Specialist nurses have expert knowledge of a particular area of nursing, and as well as offering direct care, like ‘normal’ nurses, they educate patients in the management of their condition and can provide a consistent point of contact for sufferers of particular illnesses, which can help with psychological well-being (Royal College of Nursing 2010). If the patient agrees, carers and relatives should have the opportunity to be involved in decisions about treatment and care. Kate was assisted with personal care after having her medication, especially the nebuliser. Her daughter stated that Kate has a very active social life; she enjoys going out for shopping using a shopping trolley. Notes may also indicate improvement or deterioration of the individual and prompt changes in service delivery or identify needed referrals. Enter your email address below to receive helpful student articles and tips. Re ecting on past ways of working, Lelean (1973) observed that nursing The Department of Health (2001) emphasises the importance of reducing waiting times for assessment and treatment. The number of patients who can be accommodated in the intensive care and high dependency units is limited. 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. 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. Toward Healthy Aging: Human Needs and Nursing Response. How did all this affect her ability to provide you with information during the assessment? Progress from assessment to care goals was good, and at this point an inter-disciplinary team was used successfully. Assessment tools are used by all healthcare practitioners. Planning is the second stage and is the process that the nurse and patient set achievable goals and plan how they can be achieved. Kate was referred to the respiratory nurse who is specialised in helping patients with breathing problems. Barrett, Wilson and Woollands (2012a), defined a care plan as an integrated document that addresses each identified need and risk. The importance of h olistic Therefore attention needs to be paid to the biological, psychological and social situations of the patient. Oxygen saturation level was also monitored with the use of a pulse oximeter. Personal details such as name, age, address, nickname, religion, and housing status were recorded. Through holistic assessment, therapeutic … The nurse must learn to empathise and be must be able to listen and take in information. The peak expiratory flow was monitored and recorded to identify the obstructive pattern of breathing that takes place in asthma (Hilton, 2005). The purpose of nursing process To identify client’s health status, actual or … The modified early warning scores system is an updated version of the early warning scores system, adding two parameters, a patient’s urine output and deviations from their normal blood pressure. 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?’. Did the daughter know the answer to all the questions? Kate responded well to the medication she was prescribed; normal breathing was maintained, her respirations became normal, ranging from 18 to 20 respirations per minute, and her oxygen saturation ranged from 95% to 99%. At this stage some problems may be noted and so the cycle must start again with assessment. Overall it’s a way of delving deeper into a patient’s illness and preventing more problems from arising. Sense of hearing is required to detect if the patient has noisy breathing or whether they have slurred speech.