The Royal Marsden Hospital Manual of Clinical Nursing Procedures - Lisa Dougherty [42]
Body image is highly personal, abstract and difficult to describe. The rationale for this section is to assess the patient’s level of understanding and general perception of self. This includes their attitudes about self, perception of abilities (cognitive, affective or physical), body image, identity, general sense of worth and general emotional pattern. An assessment of body posture and movement, eye contact, voice and speech patterns should also be included.
How do you describe yourself?
How do you feel about yourself most of the time?
Has it changed since your diagnosis?
Have there been changes in the way you feel about yourself or body?
11 Sexuality and reproduction
Understanding sexuality as the patient’s perceptions of their own body image, family roles and functions, relationships and sexual function can help the assessor to improve assessment and diagnosis of actual or potential alterations in sexual behaviour and activity.
Assessment in this area is vital and should include relevant feelings about the patient’s own body, their need for touch, interest in sexual activity, how they communicate their sexual needs to a partner, if they have one, and the ability to engage in satisfying sexual activities.
This may also be an opportunity to explore with the patient issues related to future reproduction if this is relevant to the admission. Below are a few examples of questions that can be used.
Are you currently in a relationship?
Has your condition had an impact on the way you and your partner feel about each other?
Has your condition had an impact on the physical expression of your feelings?
Has your treatment or current problem had any effect on your interest in being intimate with your partner?
12 Values and beliefs
Religious, spiritual and cultural beliefs
The aim is to assess the patient’s spiritual, religious and cultural needs to provide culturally and spiritually specific care while concurrently providing a forum to explore spiritual strengths that might be used to prevent problems or cope with difficulties. Assessment is focused on the patient’s values and beliefs, including spiritual beliefs or on the goals that guide his or her choices or decisions. A patient’s stay in hospital may be influenced by their religious beliefs or other strongly held principles, cultural background, ethnic origin. It is important for nurses to have knowledge and understanding of the diverse cultures of their patients and take their different practices into account.
Are there any spiritual/cultural beliefs that are important to you?
Do you have any specific dietary needs related to your religious, spiritual or cultural beliefs?
Do you have any specific personal care needs related to your religious, spiritual or cultural beliefs (i.e. washing rituals, dress)?
13 Health perception and management
Relevant medical conditions, side-effects/complications of treatment
Assessment of the patient’s perceived pattern of health and well-being and how health is managed should be documented here. Any relevant history of previous health problems, including side-effects of medication, experienced previously should be noted. Examples of other useful information that should be documented are compliance with medication regimen, use of health promotion activities such as regular exercise and if the patient has annual check-ups.
What does the patient know about their condition and planned treatment?
How would they describe their own current overall level of fitness?
What do they do to keep well: exercise, diet, annual check-ups or screening?
Postprocedural considerations
Decision making and nursing diagnosis
The purpose of collecting information through the process of assessment is to enable the nurse to make a series of clinical judgements, otherwise known as nursing diagnoses, and subsequently decisions about the nursing care each individual needs. The decision-making process is based upon the clues observed, analysed and interpreted and it has been suggested that expert nurses assess the situation as a whole and make judgements