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Assessment in Nursing Assignment

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    This assignment will discuss and define the role of assessment as a vital tool in the provision of nursing care within the Nursing process. The author will describe sources of information which may inform the assessment process, identify a specific assessment tool used in my area of practice and identify ways of developing a positive professional relationship with the client, during the assessment process.

    The assessment process may be defined as the organized and systematic collection and assimilation of data on the patient’s health status through a variety of sources: these include the patient as a primary source, along with their medical records and any information obtained from the family or any other person giving patient care. Secondary sources can be professional journals and medical texts. (Galasko,1997) The American Psychological Association defines assessment as ‘assess. (nd):to judge or estimate the value ,character ,etc of…’(Apa,2007).

    Whereas the (Oxford Dictionary for Nurses) defines it as ‘the first stage of the nursing process in which data about patients health status is collected and from which a care plan may be devised’. Traditionally, the nurse’s role has been has been one of recording but not interpreting observations including blood pressure, pulse, temperature, respiratory rate and consciousness level. Through recording this information accurately, the nurse is able to prioritize patient care, Nursing Times. net (2006).

    McCormack et al (2004), argue that ‘assessment is not just the undertaking of a set of technical skills; rather it requires a certain kind of relationship between those who participate in it and with whom we share the purposes and standards of the practice’. In its’ widest sense, assessment permeates all aspects of nursing care. It is not just a detached activity that initiates the ‘nursing process’ or ‘problem solving cycle’, leading to a plan of care, which is implemented and evaluated, it is an ongoing cycle of activity (Ryrie and Norman. 009). Assessment is central to all types of nursing activity and something common to all types of assessment is the gathering of information. Assessment data customarily describes a person’s baseline observations and appearance or behaviour, or their presentation and performance, or again the form and function of their thoughts and feelings. More broadly, assessment information encompasses a person’s overall sense of self and their position in life, including not only problems and diagnoses but also their assets and strengths (Barker 2004)

    The process of assessment can be seen as cyclical, insofar as the nurse is constantly looking for any changes, differences or other information to aid in the evaluation of the patient’s health. This is important as even the slightest detail can point to a change in the patient’s needs and require intervention. There are a variety of terms used to describe the different forms in which assessment takes place. Global assessment is concerned with the gathering of general information about the patient, e. g. hrough a more structured interview process or through the construction of a Life Map or Timeline. Specific assessments can be centered around single, disparate topics which may have had a profound emotional effect on the patients life, eg. the death of a close relative or the circumstances surrounding the first incidence of substance abuse. Qualitative information is subjective, in that it is personal to the client and has a specific meaning to them in that it acknowledges, ’their words, their story’ Barker(2000).

    This type of data is more likely to be obtained from a looser type of interview and is more reliant on the patient’s own self–evaluation. (Hall & Trotter, 2008) Quantitative information is objective, in that it is obtained through more mechanical or systematic means, such as assessment tools and rating scales. Naturally, different people may respond in different ways to different types of assessment. For that reason it is important to initiate an approach that will support the engagement process and encourage the person to express their viewpoint.

    The assessment method should be relevant to the person being assessed and it is also essential that they understand the rationale and purpose of the process used. Hall & Trotter (2008) The assimilation of information that contributes to the assessment can be achieved by these key methods: *Direct observation *Logs, diaries and records *Questionnaires and rating scales *Interviewing (Barker, 1997) This methodical approach to patient welfare is cyclical in nature and when used in nursing practice, will result in competent nursing care .

    The nursing process is advantageous to both the practitioner and the patient. When the nurse becomes accomplished in the use of this tool, they stand to acquire confidence, gain job satisfaction and personal growth and the opportunity to share knowledge (Atkinson&Murray,1995) The patient would hopefully benefit by receiving continuity of care, enhanced quality of care and greater autonomy. Having already identified the ongoing nature of the assessment process, its main aims can be identified as needing to: Establish the needs or possible needs of the person and their family *Gather information on which a plan of care may be based *Collate information that will provide a foundation for reassessment and evaluation *Act as a mechanism for quality care *Act in accordance with statutory obligations *Assist the structure of nursing knowledge (Hamilton&Price 2007) The Nursing Process is the assessment, planning, implementation of patient/client care (Carpenito-Moyet, 2005).

    This would consist of being responsible for making regular observations, the administration of medications and therapies as directed and prescribed, maintaining a patients hydration levels maintaining patency of any intravenous(IV) access, using a holistic approach to nursing, adhering to the correct policies and procedures in relation to suitable care pathways, adhering to the Code of Professional Conduct, liaising with other health professionals, families and significant others and ensuring a safe and appropriate discharge from the ward. (Quan,2007)

    The NMC (Nursing and Midwifery Council) code of professional conduct (2002) states that the patient must be respected as an individual, as opposed to simply being a set of symptoms and a diagnosis. Therefore, all the various elements which constitute that persons make up should be considered. This provides the foundation of Holistic practice. It is important to acquire knowledge and understanding of the patients’ perspectives and requirements in developing a care plan, as the care plan needs to be meaningful to the patient for it to be successful in maximizing health.

    This according to (Fawcett, 2000) means not only attending to a patients physical needs but their, sociocultural, spiritual, psychological and emotional needs as well. One way to successfully utilize the nursing process in the assessment of a patient and the planning of their care is through the use of a nursing model. Perhaps, the most widely used of which is ‘The Activities of Living Model’ (Roper, Logan and Tierney 1980).

    This model of nursing specifies twelve activities of daily living which are related to basic human needs. These consist of maintaining a safe environment, communicating, breathing, eating and drinking, eliminating, personal cleansing and dressing, controlling body temperature, mobilizing, working and playing, expressing sexuality, sleeping and dying. Assessing a patient who is undergoing a serious episode of mental illness is possibly one of the most serious procedures a mental health nurse will have to undertake.

    Sullivan (1990) plainly states that the consequences of an incorrect assessment or the misinterpreting of a patients presentation, could lead to a patient not receiving the appropriate treatment at the right time through to the occurrence of a fatality due to non admission to mental health services. The ability to put together a thorough and accurate account of the patients ‘presentation’, for continual involvement of the multi-disciplinary team, along with the initialisation of the care plan and care pathway programme is vital to this process.

    In the area of Mental Health, one of the commonest and most frequently used assessment tools is the Mini-Mental State Examination or ‘M. M. S. E’ Folstein (1975). This is a widely used method of detecting cognitive impairment and monitoring its progress, especially with people who have or are thought to be suffering from dementia or Alzheimer’s Disease(AD). As it is a relatively short and simple test, one that is to quick to carry out, it is ideal for repeated and routine application in this field.

    The test itself, is a questionnaire consisting of eleven questions which aim to evaluate the level of an adult patient’s cognitive function, Nursing times (2007), by appraising six areas of cognitive function; orientation, attention, immediate recall, short term recall, use of language and the ability to follow simple verbal and written commands, Folstein (1975). The M. M. S. E. Folstein (1975) is split into two sections; the first of which allows a maximum score of 21 points and the second part a maximum of 9 can be achieved by correctly answering all the questions and reproducing simple patterns.

    The resulting score then allows the examiner to grade the patient against a scale of cognitive function. A result above 27 points (30) is considered normal; a score below 24 suggests dementia, dementia with a rating 23-21 mild, 20-11 moderate dementia, less than 10, severe dementia (Norman, Ryrie,1990). Prior to implementing the M. M. S. E. Folstein (1975) test it is important to have a baseline knowledge of the patient ie: a review of the patient’s history. As well as talking to the patient, a comprehensive medical, social and biographical history can be obtained by accessing the patient’s case notes, talking to other professionals and also talking to family members of the patient (Bush 2007). The cognitive assessment of older people with dementia can vary; different practitioners may use contrasting assessment criteria, assessment tools and rating scales and those that are used have a number of flaws which may obstruct their accuracy and validity as diagnostic tools, Bush (2007).

    Nevertheless, practitioners still require a guide for the prescription and evaluation of care, as the assessment of patients as ‘individuals’ is essential to the planning of an holistic approach to their care and treatment. The M. M. S. E. can be completed in ten minutes or less, Mungas (1991) and was created for use with elderly patients who are able to co-operate at an optimal level for only short periods of time, no longer than a few minutes. Folstein et al (1975). According to Nice (2007) the most commonly cited measures have been obtained through the implementation of M. M. S. E. Folstein (1975).

    Bush, Nursing Times (2007) argues that there would seem to be very little doubt that the M. M. S. E, Folstein (1975), is seen to be the ‘gold standard’ as an assessment tool for the measurement of cognitive function in dementia sufferers in both Europe and the U. S. A. According to some researchers however, it would appear to be far from ideal. It has been argued that its accuracy is reliant on several variables including the age, ethnicity and educational background of the patient. Boustani et al. have argued that the test is more accurate for white people with a high school education. Similarly, Yebenese et al. rgue that accurate completion of the M. M. S. E, Folstein (1975) is dependent on the patient having at least a fundamental level of learning and a certain degree of both literacy and numeracy which could exclude people from different cultural, ethnic or social backgrounds from obtaining a truthful assessment. According to NICE Guidance (2011), when people take the M. M. S. E. ,Folstein (1975), the information provided should be culturally appropriate and in a form that is accessible to people who have additional needs, such as physical or sensory disabilities, or who do not speak or read English.

    There are also external factors, which may have a negative influence on the outcome of the test results, namely the time of day when the test is carried out. As the day progresses the individuals stress levels may increase, with older patients in particular becoming more tired and having difficulties with concentration, possibly resulting in a poorer performance, which could provide the examiner with a false score. Dewing (2003). Bender (2003) has argued that the results of the M. M. S. E. Folstein (1975) can also be influenced by how it is administrated and by the surroundings in which the test is undertaken.

    A quiet area, rather than a busy dayroom would be deemed more conducive to the production of an accurate result. Even though the soundness of this test has been questioned, it still remains the tool most commonly used by mental health practitioners in the assessment of older patients with Alzheimer’s disease, Bush (2007). Moby’s Medical Dictionary (2009), defines ‘therapeutic communication’ as a process in which the nurse consciously influences a client to a better understanding through verbal and nonverbal communication.

    For this reason, effective communication is a vital tool in the development of a positive, professional relationship with a patient or client. The Nursing and Midwifery Council (NMC) advocates the importance of the nurse patient relationship in the code of professional conduct, which indicates that nurses are responsible for developing and maintaining appropriate relationships. It also advises that nurses must listen to the people in their care and respond to their concerns. NMC (2008). When proceeding with the assessment of a patient, it is essential to communicate effectively and for the nurse to be able to establish some form f empathy in order to establish an atmosphere of genuiness, acceptance and unconditional positive regard, which is vital if a therapeutic relationship is to be developed successfully. Empathy can be communicated both verbally and non- verbally. A useful tool for this is ‘Active’ listening. (McWhinney, 1989). Egan (1986) defined the acronym SOLER as a reminder for the assessor, of the behaviours, or physical tactics which can be used to facilitate communication and improve their own reception of information.

    This entails facing the other person Squarely and adapting an Open posture, Leaning toward the patient slightly, to promote intimacy, maintaining Eye contact, to show interest and being Relaxed to put the patient at ease . This can be of use to the patient as it infers that the assessor is genuinely interested in them and what information they have to impart. A verbal listening technique is ‘reflective listening’, during which the nurse listens to and then mirrors what the patient has said thereby reflecting back the patient’s own ideas and feelings. Egan (2002) ‘If we could all just learn to listen, everything else would fall into place.

    Listening is the key to being patient centred‘. McWhinney (1989) This assignment has defined and explored the role of assessment as an integral part of the nursing process and has discussed how a specific assessment tool can be implemented within a specific area of practice, ie. Mental Health. Although, there are many tools that can be utilized throughout the assessment process, it is the ability to treat each patient as an individual and listen to their own personal needs and requirements, which should always remain as the main focus. References American Psychological Association (APA) (2007).

    Dictionary. com Unabridged (v 1. 1. ) Atkinson, L & Murray,E, (1995). Clinical guide to care planning, McGraw Available at : http//dictionary. reference. com/browse/assess (Accessed 31 October 2011) Barker , P. J. (2000). The Tidal model: From Theory to Practice. Newcastle:University of Newcastle. Barker ,P. J. (2004) Assessment in Psychiatric and Mental Health Nursing : in Search of the Whole Person (2nd edn). Cheltenham : Nelson Thornes Ltd. Bush,T (2007) Use of cognitive assessment with Alzheimer’s disease: Nursing Times,2007 Jan 9-15 ; 103(2): 31-2 (9ref) (Accessed: 02 ,November ,2011)

    Carpenito – Moyet , L. J. (2005) Nursing Diagnosis: Application to Clinical Practice,11th edn . Philadelphia : Lippincott ,Williams and Williams Dewing, J. (2003). Rehabilitation for older people with dementia. Nursing standard : 18:6,42-48. Egan,G,( 2002). The Skilled Helper :a problem – management and opportunity- development approach to helping. 7th ed. California: Brookes / Cole Folstein,M. , Folstein,S. and McHugh,P. (1975) Mini mental state examination: a practical method for grading the cognitive states of patients for the clinician. Journal of Psychiatric Research.

    Galasko ,D . ,et al. (1997). An inventory to assess activities of daily living for clinical trials in Alzheimers Disease and Associative Disorders,11 (Suppl. 2),s33-s39 Hall,A & Trotter,J,(2008). : Care Planning in Mental Health (promoting recovery. )Blackwell Publishing Ltd. McCormack, B et al. (2004),practice development in nursing, Blackwell McWhinney,Jr. A textbook of family medicine. Oxford: Oxford University Press,1998. Mosby’s Medical Dictionary,8th Edition,2009,Elsevier. Mungas,D (1991) ‘ In office mental status testng ; a practical guide’. Geriatrics 46 (7): 54-56

    NICE ,guidelines: Dementia:Supporting people with dementia and their carers in health and social care : Available at : http:egap. evidence. nhs. uk/dementia-cg42/person-centred—care. (Accessed: 05, November,2011) NMC (2008) ‘Code of Professional conduct’ Nursing and Midwifery Council available at:www. nmc-uk. org/aFrameDisplay. aspxDocumentId=3954 Norman ,I & Ryrie ,I,(2004),The Art and Science of Mental Health Nursing: a Textbook of Principles ,Open University Press NursingTimes. net, The impact of accurate patient assessment on quality of care, 7 February,2006, Vol: 102, ISSUE :06,Page No 34

    Quan ,Electronic Healthcare,(2007) at http:longwoods. com/product. php? productid=186588&cat (Accessed:01, November , 2011) Roper,N,Logan,W. W and Tierney,A. J. (2002). The Elements of Nursing: A model for nursing based on a model for living. 4th Edition. Churchill Livingstone. Sullivan,J. (1990). Neurological assessment. Nursing clinics Of north America,25 (4),795-809 Yebenese et al (2003) Validation of a Short Cognitive Tool for The Screening of Dementia in Elderly People with Low Educational Level. International Journal of Geriatric Psychiatry : 18: 925-936

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