Key Nursing Skills PDF ebook

It is important to appreciate that assessment is fundamental to all procedures that a patient may undergo. It does not happen just once but is an ongoing process repeated at regular intervals depending on the patient’s condition.
The most usual time for a thorough assessment to occur is when a patient is admitted to acute or continuing care, but there may be other times when further detailed assessment is necessary. Assessing a patient involves both formal and informal assessment.
Formal assessment includes the gathering of objective information about the patient’s condition by interviewing him or her and obtaining answers to questions. Informal assessment includes the things that you notice about a patient while you are talking to them, and may include physical signs and subjective information such as their mood or behaviour.
The structure of these assessments will be discussed in more detail in this chapter. Assessment of physical vital signs is also undertaken and these are described more fully in Chapter 2. An effective assessment will ensure that a patient receives all the nursing care that is required, and will provide a baseline from which progress can be measured. To ensure that nursing care is planned and delivered effectively a structured approach called the ‘nursing process’ is used. The ‘nursing process’ is a planned, problem-solving approach to meeting a patient’s health care and nursing needs (Lippincott 2000).
It is a systematic sequence of events in which the first stage is to assess a patient’s needs by the collection of objective and subjective information. The next stage is interpretation of this information, which results in the identification of actual or potential problems that the patient is experiencing. This can be called making a nursing diagnosis (Lippincott 2000).
Nursing goals to alleviate or prevent these problems can then be determined and problems prioritized so that the patient’s immediate nursing care needs are met. These goals are used to plan the direction and type of nursing interventions required. They should be patient-focused, and SMART:

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