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.
It is necessary to involve the individual in the plan of care and support. Encourage the individual to make choices. This includes their needs, their culture, their means of communication, their likes and dislikes, wishes and feelings, advance directives, beliefs and values, involvement of their family and other professionals. This should be considered and documented. Also, there must be evaluation in assessing effectiveness in the plan of care.
The purpose of this assignment is to explore a needs orientated approach to care planning, through the use of a problem solving approach to care, and a nursing model. It aims to show an understanding of what both a problem solving approach to care, and a nursing model are; and to establish how various key elements of both are implemented in practice. The following citation by the Department of Health (DH) (2009) identifies what is intended by the process of care planning;
Before any nursing plan of care or intervention can be implemented or evaluated, the nurse assesses the
A problem solving approach is a process of planning care for a patient (McFerran and Martin, 2003) using ASPIRE, based on APIE (Yura and Walsh, 1988); Assessment, Plan, Implementation and Evaluation. ASPIRE is a nursing process which includes six stages: assess, a systematic nursing diagnosis, plan, implement, recheck and evaluate (Barrett et al, 2012). Using a range of assessment tools, some potential risks can be identified although, these tools should be used as guidance for treatment and not used in the decision making process as to who and who does not receive treatment, (National Institute for Health and Care Excellence (NICE), 2011) but through gaining consent during each process, as it should be before any care or treatment (NMC, 2008).
• Administer Care Plan in order to ensure that it is delivered in an appropriate, caring and respectful
This helped me create a specialized plan of care for my patients and their families.
Nursing care is focused on the assessment, nursing diagnoses, planning, implementation, and evaluation of patients. This nursing process can also be implemented in aspects outside of nursing and on the nursing field as a collective group. The nursing role is evolving, following the process the outcomes have to be evaluated and put into perspective. Research is being completed the conclusions are all the same, the higher education of nursing care the better the patient outcomes.
As you learned in NR302, before any nursing plan of care or intervention can be implemented or evaluated, the nurse conducts an assessment, collecting subjective and objective data from an individual. The data collected are used to determine areas of need or problems to be addressed by the nursing care plan. This assignment will focus on collecting both subjective and objective data, synthesizing the data, and identifying health and wellness priorities for the person. The purpose of the assignment is twofold.
Closely linked to this decision-making model is the ubiquitous nursing process. The nursing process includes data collection and documentation, analysis of the data to determine current condition and real or potential health related issues, development of an individualized plan of care to deal with these issues, implementation of that plan of care, and evaluation of the plan of care to determine its effectiveness and adjust the plan as needed. (Blais, Hayes, Kozier, & Erb, 2006)
Assessment is described as”The first stage of the nursing process, in which data about the patient’s health status is collected” (Oxford dictionary of nursing, 2003, p23), following this phase a care plan can be devised.
Follow the guidelines as explained in care plans, which is important, so you will know what each individual needs and their risk assessment.
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).
The nursing process is a five stage systematic framework, and based on the problem solving approach; it forms the foundation for nursing practice to facilitate focussed, individualised care planning for patients (Yildirim and Ozkahraman 2011). This assignment will serve to identify the five stages of the nursing process: Assessment, Nursing Diagnosis, Planning, Implementation and Evaluation. The skills: Communication, Observation, Critical Thinking and Reflection involved within the nursing process in partnership with the patient will also be highlighted.
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).