Assessment
This assignment will describe the assessment of a client that the student nurse has worked with and show how a holistic approach to the assessment process was used and the importance for this. Reference to the academic theory that support and are the reasons behind the student’s actions will be made throughout.
The nursing process contains four stages based around the individual: –
The first and most important stage of the nursing process is assessment where good communication skills are essential to the nurse to allow her to identify problems with the client; actual and potential, physical and psychological (Kenworthy et al 2001).
One of the most important nursing skills is the ability to assess the client as this is the first stage in the nursing process and is vital to obtain the information that will allow the nurse to plan and implement nursing care and evaluate their effectiveness (Smeltzer & Bare 2003).
The client’s details have been changed to maintain client confidentiality in accordance with the NMC Code of Professional Conduct 2004.
“Anastasia Beaverhausen”, aged 78, was admitted to hospital for treatment of a fractured neck of femur. Shortly after Anastasia’s arrival to the ward, the nurse assessed the client’s blood pressure, pulse, temperature, respiratory rate and oxygenation levels (SP02). This gives the nursing team a baseline to monitor Anastasias future observations against to determine any progress or deterioration of the client’s health. The wards assessment model was loosely based around the Roper, Logan and Tierney, and was used to begin the first stage of the nursing process. This wards model used the 12 activities of daily living designed by Roper et al which are maintaining a safe environment, communication, breathing, eating and drinking, elimination, washing and dressing, thermoregulation, mobility, working and playing, expressing sexuality, sleeping, death and dying (Holland 2005) with the added assessment of skin/pressure areas.
The assessment interview allows the nurse-patient relationship to be established on the basis of mutual concern for the patient’s well being. However, the interview must have a structure and contain a beginning and an ending, and should progress logically, ensuring meaning to the participants (Mallet & Dougherty 2000).
The nurse began by introducing herself to the client and explaining what she was going to do. In accordance with the NMC 2004 where it states that nurses must promote and protect dignity of clients, the nurse pulled the curtains around the client’s bed space to promote the client’s privacy. A private room would have been a better place to undertake the assessment, as other patients could potentially still overhear, however this was not available and the situation was dealt with to the best of the nurse’s ability. The nurse informally chatted to the client to begin to build a relationship with her. She did this to help make the client feel at ease with her and therefore feel able to express her feelings and concerns as some problems may not be disclosed by the client and may only be identified when the nurse-client relationship develops and the client feels able to trust the nurse (Mallet & Dougherty 2000).
To do this, the nurse positioned herself near to the client and used warm body language and eye contact. At this early stage of interaction, both verbal and non-verbal communication skills are extremely important, as any relationship comes about through communication (Nolan 2003).
To enable the nurse to identify any interrelated problems, a holistic approach to the assessment was required. The term comes from the Greek word ‘holos’, meaning ‘whole’. By applying the holistic approach to health care, the nurse takes places emphasis on the whole person, taking into account the physical, emotional, intellectual, spiritual and cultural background and needs of the individual rather than simply treating the symptoms of their illness (Kenworthy et al 2001). And upon review of the many nursing theories currently in use, it is clear that they all take into account the whole person (George 1995).
Early on in their conversation, it was established that Anastasia was very concerned about her dog that had been left at home with no-one to look after it. She was extremely worried about this and the nurse noted that this was a holistic need of the client that needed to be addressed. This emphasizes the importance of a holistic approach, because although it was not a symptom of the client’s injury, it was causing her to feel anxious and distressed. To gain Anastasia’s trust and her acceptance of her treatment plan, the nurse had to address this issue so the nurse asked the client if there was anyone that she could contact on her behalf and if Anastasia would be happy for this person to take care of her dog. The client remembered that her neighbour, who was a close friend, had a key to her house and that it would put her mind at rest if she knew she could care for the dog.
For the purpose of this essay, the focal point will be on three of the activities of daily living that relate most to the client. For Anastasia, these were Eating and Drinking, Mobility and Skin / Pressure Areas. These were chosen because nutritional weakness and injury may also result in loss of muscle, and possibly decrease the client’s mobility and increase the likeliness of pressure sores and therefore increase recovery time. Through building a relationship with Anastasia, the nurse was mostly able to complete the assessment without asking too direct questions and therefore creating a feeling of formality for Anastasia, as clients may be reluctant to offer information around having a fall for fear of being put in a home or the need for a walking aid (Delorito 2002).
During their discussion the client explained that her injury was the result of a fall after she slipped on some ice while out walking. Through talking to Anastasia about her previous medical history and reading the clients notes, the nurse saw that there had been no record of any previous slips or falls. It is important to ask the client if she has had any previous slips or falls, as a history of these is one of the most common risk factors for future falls (Delorito 2002). It was reported to the nurse by the client that she was a very active and social lady and she hoped to return to her normal life as soon as possible. The nurse was able to gain a picture of Anastasias mobility through their interaction, and noted that she usually walked unaided, had no stairs at home as she lived in a bungalow and took her dog for daily walks. The nurse also made a visual assessment and saw that the client was able to move positions in bed reasonably well which would therefore aid keeping her pressure areas in tact but she seemed to be in pain by doing so. To enable the nurse to assess how much pain Anastasia was in, she asked her to describe her pain on a scale of one to ten, with ten being the worst and zero being no pain at all. The client reported six on this scale and the nurse noted that this could hinder her movement while on bed rest and potentially lead to pressure sores.
The nurse explained to Anastasia that she would have to remain on bed rest until the fracture had been stabilized and informed her as to how and why pressure sores form and that she could potentially be at risk, and for this reason, the nurse would need to carry out a Waterlow Assessment. Thus is in accordance with the NMC 2004 where it states that nurses must recognise and act to minimize the risk to clients. The Waterlow assessment is a tool used to determine the risk status of the client, and professional judgment must still be used. It allows clients to be classified according to their risk of developing a pressure sore under the categories of weight for height, continence, skin type, mobility, sex and age, appetite, and special risks such as tissue malnutrition, neurological deficit, major surgery or trauma and medication.
To complete the weight for height score with, a body mass index (BMI) calculation must be carried out. This is a measure which takes into account the client’s height and weight to measure their body fat and can alert nurses to possible health risks for the client; the higher the BMI, the bigger the risk is of developing further health problems such as diabetes, high blood pressure and heart disease (Lee & Neiman 2002). As the nurse was unable to measure and weigh Anastasia, she used information provided by the client to calculate her BMI. The nurse also asked to look at the client’s pressure areas to see if there was any evidence of any sores, either healing or beginning and noted that there were none.
As part of the assessment process, the nurse also needed to assess Anastasias nutritional status. Nutritional assessment is a crucial part of nursing care (Horan 2000) as this would help the nurse to identify if the client was undernourished, the possible reasons for this, and to provide a baseline for any future care given (Gibson 2005). Because a good diet is essential to the healing process it is vital to know if the client was getting the proper nutritional intake. The nurse needed to take the clients diet history, including food frequency, habits, preferences, meal patterns, and possible religious restrictions (Lee & Neiman 2002). To do this, the nurse spoke to the client about what she would usually eat at home and asked her open questions beginning with how and why, for example, creating a much greater chance of the client feeling able to express their feelings rather than simply answering “yes” or “no” (Nolan 2003). This extra information given by the client enables the nurse to gain a more comprehensive picture of Anastasias eating and drinking habits. The client became upset and reported that she had had a loss of appetite over the past two months since her husband had passed away. This was also why she was so anxious about her dog and hoped to return to her normal routine and social activities as quickly as possible as she feels that this helps her to cope with her loss. The nurse also noted, through a visual assessment of the client that her skin was dry, indicating dehydration. This was verified when the nurse asked Anastasia what she would normally have to drink in a day, including alcohol, as the client reported that she drinks only two to three cups of tea per day and drinks a glass of cherry on special occasions only, enabling the nurse to confirm her belief that the client also had an insufficient fluid intake as clients should be encouraged to drink 2-3 litres of water per day (Gibson 2005). As part of the nutritional assessment, Anastasia was also asked if she had any dentures, was taking any vitamins, minerals or supplements, and if she had any food allergies, to which the client explained that she had a full set of dentures, took no supplements, but was wheat intolerant and found this hard to cope with, which also influenced her eating habits as she cant eat the simple snacks she would like to because she is no longer cooking regular meals. The nurses visual assessment, and noted that the clients clothes and rings seemed a little loose, indicating a recent weight loss (Lee & Neiman 2002). The nurse also noted that a lack of sufficient nutrients could have influenced the clients fall if she was weakened by a poor diet, as vitamin D is an essential nutrient for bone health and a major cause of its insufficiency is poor nutrition (Gennari 2001).
While speaking to Anastasia the nurse made notes that she could refer to later. This was done to allow the client-nurse interaction to continue a little smoother than if the nurse was to repeatedly stop to document and to create a more relaxed atmosphere. After the assessment, the nurse used her notes to record and document all her findings clearly and legibly onto the clients assessment form, promoting effective communication between other health professionals and in accordance with the NMC Code of Professional Conduct 2004.
CONCLUSION
It has been established that the assessment is probably the most important stage of the nursing process because if it is done without care or inaccurately it will affect the planning, implementation and evaluation stages and possibly the clients care.
Perhaps the most important factors to the assessment process are good communication and good documentation. A good assessment is dependant on the relationship between the nurse and the client and the most important aspect of all nursing activities are those that promote professional, compassionate, human to human interaction (Weber & Kelley 2003). Good documentation remains in line with the NMC Code of Professional Conduct 2004 as it promotes better communication, consistency, continuity, efficiency, and professionalism within the nursing team (Wood 2003).