F. Nursing Process

Assessment

What components are needed for a successful assessment

·       Good communication

·       A systematic approach to data collection

·       Interpretation based on nursing knowledge

Objective (scientific Quantitative)

·       Empirics measurement of knowledge with scientific fact

Subjective (Art, Qualitative)

·       Aesthetics gained through empathy and is how a nurse becomes sensitive to a patient’ s pain,worry or joy

·       Ethics concerned with motivation, morality, human rights and law

·       Personal knowledge awareness that the nurse has an impact on patient care

Sources of Data

1. Non verbal observation

·       Sight - Physical, psychological (and social)

·       Touch – Skin, temp, hydration, pulse/BP

·       Sound – Breath wheeze, stridor

·       Smell - breath

·       body fluids infections, gangrene 

2. Verbal Communication

·       Patients/ clients

·       Family and friends (Meaningful others)

·       Nursing colleagues

·       Medical colleagues

·       Other members of multidisciplinary team

3. Written records

·       G.P Letter

·       Transfer letter

·       Old notes

Communication

Why are good communication skills required?

·       To establish and maintain a relationship with patients and their families

·       To encourage patients to describe all relevant aspects of their problems

·       To get and give accurate information

·       To use time and opportunity effectively

·       To improve patient satisfaction with the care given

·       To improve thrust and cooperation with the care

·       To reduce negative emotions and fear

Guide to a successful assessment

·       Prepare adequately

·       Introduce yourself - prepare patient

·       Use nonverbal communication

·       Be courteous

·       Use sensitivity, compassion and empathy

·       Use focused questions (opened and closed)

·       Listen

·       Clarify

·       Summarise what they describe

·       Make notes

Planning

Effective planning depends on the quality and comprehensiveness of the assessment

·       Determine the problems

·       Establish the risks and priorities – How ill are they?

·       Can they breath adequately (safe airway?)

·       Are they in pain? (physical/ psychological)

·       Can they maintain a safe environment? If not why not? (Drugs, drink, mental or psychological problem?)

·       Noncompliance with medical advice

Writing a care plan (s)

Think about

·       Who is it for ?(The patient and other members of nursing team)

·       What are the short term and long term goals?

·       How can you determine that you have reached the goals? (measurable)

·       How will the patient know he/she has achieved the goals? (realistic)

·       Who is involved in the delivery of the care? (The patient (and family), yourself, the nursing team, medical staff, multidisciplinary team, labs, investigations, procedures etc)

·       How quickly is the problem likely to change – How soon will you need to reevaluate the plan?

·       How many problems are there? - Which order of priority?

·       How can you prove that they are evidence based (what resources do you need?) (core care plans Vs

·       individualized ones)

Implementing

a) At the start of the shift, during handover and when you first meet them, think about whether the oral report matches the patients actual condition

b) Compare this to what you already know of the patient and to the existing care plans

c) Has anything changed for better or worse

d) Decide:

What are the priorities for looking after this patient?

• Is their condition stable? What observations

need doing how often

• Are they going off the ward tests/investigations/operations

• Are they being discharged? When are they going? Is every thing ready?

Repeat this process for all the patients you are looking after.

e) What routine work must be done and when should this be done

f) Who is going to do this work are you on your own or do you have a Clinical support worker with you? How will they give you feedback?

g) Who is available to give you help or advice if needed? (senior nurse medical team)

h) How are you going to organize the work - TIME MANAGEMENT

i) What resources do you need?

Evaluation

MENTAL - On going throughout implementation

WRITTEN -  (this should preferably be done with the patient present in order to get accurate feedback)

·       Must be carried out at least twice in 24 hours

·       And whenever any incident occurs. (date, time

signature)

·       Write a general statement about patient’s condition

(better, same, worse)

·       Evaluate each care plan in turn and by number

·       Personalize - use patient’s own words appropriate

·       State what care you have given “C are of planned” or any variation/ comment e.g. “pressure area care given skin slightly red on …sacrum”

·       Amend the care plan if circumstances have changed

·       Discontinue care plans if the goal(s) have been reached

·       Legally- if the care given has not been recorded than it hasn’t occurred!