The Royal Marsden Hospital Manual of Clinical Nursing Procedures - Lisa Dougherty [33]
UKCC (1992) The Scope of Professional Practice: A UKCC Position Statement. United Kingdom Central Council for Nursing, Midwifery and Health Visiting, London.
Walsh, K. and Kowanko, I. (2002) Nurses’ and patients’ perceptions of dignity. International Journal of Nursing Practice, 8 (3), 143–151.
Walsh, M. and Ford, P. (1989) Nursing Rituals, Research and Rational Actions. Heinemann Nursing, Oxford.
Williams, A.M. and Irurita, V.F. (2004) Therapeutic and non-therapeutic interpersonal interactions: the patient’s perspective. Journal of Clinical Nursing, 13 (7), 806–815.
Willis, W.O. (1999) Culturally competent nursing care during the perinatal period. Journal of Perinatal and Neonatal Nursing, 13 (3), 45–59.
Wilson, C. (2005) Said another way. My definition of nursing. Nursing Forum, 40 (3), 116–118.
Chapter 2
Assessment, Discharge and End of Life Care
Overview
This chapter will give an overview of a patient’s care from assessment through to discharge and will include care of the dying and procedures after death.
Assessment is considered to be the first step in the process of individualized nursing care. It provides information that is critical to the development of a plan of action that enhances personal health status. It also decreases the potential for, or the severity of, chronic conditions and helps the individual to gain control over their health through self-care (RCN 2004). Assessment forms an integral part of patient care and should be viewed as a continuous process.
Inpatient assessment and the process of care
Definition
Assessment is a systematic, deliberate and interactive process that underpins every aspect of nursing care (Heaven and Maguire 1996). It is the process by which the nurse and patient together identify needs and concerns. It is seen as the cornerstone of individualized care, a way in which the uniqueness of each patient can be recognized and considered in the care process (Holt 1995).
Related theory
Principles of assessment
The process of assessment requires nurses to make accurate and relevant observations, to gather, validate and organize data and to make judgements to determine care and treatment needs. A nursing assessment should have physical, psychological, emotional, spiritual, social and cultural dimensions, and it is vital that these are explored with the person being assessed. The patient’s perspective of their level of daily activity functioning (Horton 2002) and their educational needs are essential to help maximize their understanding and self-care abilities (Alfaro-Lefevre 2002). It is only after making observations of the person and involving them in the process that the nurse can validate their perceptions and make appropriate clinical judgements.
Effective patient assessment is integral to the safety, continuity and quality of patient care and fulfils nurses’ legal and professional obligations in practice. The main principles of assessment are outlined in Box 2.1.
Box 2.1 Principles of assessment
1 Patient assessment is patient focused, being governed by the notion of an individual’s actual, potential and perceived needs.
2 It provides baseline information on which to plan the interventions and outcomes of care to be achieved.
3 It facilitates evaluation of the care given and is a dimension of care that influences a patient’s outcome and potential survival.
4 It is a dynamic process that starts when problems or symptoms develop, which continues throughout the care process, accommodating continual changes in the patient’s condition and circumstances.
5 It is essentially an interactive process in which the patient actively participates.
6 Optimal functioning, quality of life and the promotion of independence should be primary concerns.
7 The process includes observation, data collection, clinical judgement and validation of perceptions.
8 Data used for the assessment process are collected from