Focused Assessment: Key Component Of Nursing Practice

The first step in the nursing process is assessment due to the fact that assessment is seeing the patient and determining what level and type of care needed (Jordan, 1999, p.12). The nursing process is a process used by nurses to integrate all aspects of assessment into one single guideline. There are 5 stages to the

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.

Through basic observations, health professionals are able to evaluate the performance of an individual’s health status. In relation to Casey, it is noted in her Observation Chart that in the time span of two hours the patient’s health status had changed from being relatively normal (to the patient) to an increased respiratory rate, heart rate and temperature as well as a decrease in blood pressure. It is also noted that the patient has a score of 8 in the pain scale (compared to the score of zero two hours previously), relating to the lower abdomen. Programs such as Between the Flags acknowledges the fact that the early recognition of deterioration of patients can reduce harm to patients through designing and implementing systems which provide a structural response in the event of a deteriorating patient, such as Rapid Response and Clinical Review. There are two phases involved in the rapid response, which includes the afferent phase and the efferent phase. The afferent phase focuses on the overall monitoring and recognising the deteriorating patient whereas

Susan is a 78 year old widowed lady who was admitted to a medical ward following an episode of coffee brown vomiting and breathlessness. Susan has a past medical history of chronic

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

Assessment of a patient is a big process of decision making, it is about the collection of information which will contribute to an overall judgement of a person and the illness they may have. Lloyd (2010) states that assessment is one of the first steps which is needed to be done in the nursing process, it is a building block for a relationship and an ongoing process which lets health professionals gather the correct information to help them understand the problems and needs that the patient is going through. Most of the nursing assessment which are in use today will all have very similar aims. The difference is that how the assessment’s are carried out is where the differences come from.

The head to toe physical assessment is the first step of the nursing process and is a systemic approach of collecting objective (physical) and subjective (mental) data on the patient that will help the nurse formulate nursing diagnoses and plan patient care. It is also used to confirm or question data that was stated in the pt. previous history stated in the charts and to evaluate the effectiveness of the nursing interventions that were carried out on the patient. The main focus of the head-to-toe assessment is to focus on what the patient is currently presenting with; the patient's responses to actual or potential problems.

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.

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.

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

Gathering observations of patients is a vital task that all Nurses must complete on a regular basis, they include Blood pressure, respiration rate, pulse, temperature and oxygen saturation. The information gathered from the observations enable for warnings when a patient is deteriorating

Health assessments are essential for patients because it identifies any abnormalities or problems with the patient’s body. Nurses must be capable to perform a head to toe assessment and communicate with the patient if something foreign is identified in their assessment. The assessment I performed had all of the key aspects, but had some errors that need improvement. This paper will identify some of my errors, a plan to mend these errors, and promote gratitude for performing the health assessment.

Upon evaluating the effect of past five week’s classes and course material encounters each week was enchanting for me. I have had great impact on my practice with those new gained and reinforced knowledge .While reading some of the materials I realized how important the legal value of our documentation .As nurses often we do give priority to our patients care and charting as our last priority .Whatever care we give if we are not documenting its considered as not done .when it reaches court of judgement our documentation is our proof .Other impact was on the focused assessment .As our patient population mostly belong to the repeated visit for chemo therapy ,focus is mainly on the focused assessment ,my new knowledge assisting me to do focused assessment in a more systematic way. Acronyms like VINDICATE was new to me even though familiar with SOAP I never used SOAPIE before.

Nurses are a vital component in patient care. The importance of conducting efficient nursing assessments is critical in order to provide both patient-centered care and safe, effective patient healing. Nurses are often responsible for taking care of patients with very complex disease processes. They frequently provide care to patients with illnesses such as Chronic Obstructive Pulmonary Disease (COPD). According to the Centers for Disease Control and Prevention, in 2014, approximately 6.8 million adults were diagnosed with COPD within the Unites States. The completion of proper assessments and initiation of interventions for these patients are crucial in order to prevent further complications of the illness.

This essay will demonstrate appropriate patient assessment and clinical decision making from physical symptoms, psychological state and social constraints and supports and its application to nursing. Clinical reasoning is regarded as the hallmark of the expert nurse. As the nurse is the first point of patient contact in patient care there is an expectation that the nurse will be in a prime position to identify when a patient is at risk or experiencing a critical event through the presentation of warning signs. If these warning signs are missed, or not managed correctly it could result in patient deterioration, to a point where suitable rescue may not be achieved (Levette-Jones et. al. 2010).