Nursing assessment
Assessment of older people [link]
Activities of living [link]
The single assessment process [link]
Nursing models and assessment in practice [link]
History taking [link]
Assessment tools in nursing: a framework for advanced nursing assessment [link]
Physical examination and assessment: a body systems approach [link]
Assessment of older people
Assessing the needs of an older person with complex social, psychological, and medical presentation requires a co-ordinated interdisciplinary approach. Failure to undertake a thorough comprehensive assessment can be catastrophic for the older person and their family.
Assessment is the foundation for planning and delivering effective nursing care. Nurses who co-ordinate this process must ensure that patient choice and autonomy are central to the assessment and care planning process.
Nursing models
Nursing models aim to provide a systematic structured approach to assessment. A range of nursing models are described in the literature, the most common model used in the United Kingdom is ‘The Nursing Process’ supported by ‘The Activities of Living Assessment Framework’.
The nursing process
The nursing process was published in the 1950s, and describes a practical cyclical approach to nursing care, starting with identification of patient need, and progressing through stages of planning, implementation, and evaluation. Four steps described in this process are:
• Assessment
• Planning
• Implementation
• Evaluation.
It is important to recognize that goal setting is the essential driver for planning care and that models are somewhat “dated” and are rarely used in practice.
Activities of living
Roper, Logan, and Tierney updated their theory, the ‘Activities of Living’ in 2000. This nursing model, one of the most popular in the United Kingdom, provides a structure for the assessment of a range of physical, social, and psychological domains that determine health status. The aim of the model is to systematically identify functional deficits requiring nursing support or intervention. The model consists of four key elements that link together, which must be considered for the effective and proper use of the model.
Activities of living
• Dependence
• Independence continuum
• Lifespan
• Factors affecting activities of living.
All underpin many specialist nursing assessments.
The domains include:
• Maintaining a safe environment
• Communicating
• Breathing
• Eating and drinking
• Eliminating
• Personal cleansing and dressing
• Controlling body temperature
• Mobilizing
• Working and playing
• Expressing sexuality
• Sleeping
• Dying.
In order to continue to meet the ever-changing requirements of nursing and of individuals who require nursing care, the role of nursing models need to be considered in both current and future practice.
The interplay of the nursing assessment with that undertaken by other specialist professionals, including health and social care, is essential in providing effective healthcare for older people.
The single assessment process
The concept of a generic multidisciplinary assessment of adults was introduced to British health policy in 2001. The purpose of introducing a single assessment process (SAP) within the National Service Framework for Older People (NSF) was to reduce duplication of assessment between professions, improve communication through shared records, and encourage active patient participation in the assessment process.
A number of single assessment models exist, they aim to make sure older people needs and wishes lie at the heart of the process
SAP domains include:
• Users perspective
• Clinical background
• Disease prevention
• Personal care and physical well-being
• Senses
• Mental health
• Relationships
• Safety
• Immediate environment and resources.
Four types of assessment have been identified:
Contact assessment
The first contact between an older person, and health or social services, where significant needs are first described or suspected. Basic information is recorded and explored.
Overview assessment
May continue on automatically from the contact assessment and ensures a more ‘balanced’ assessment by exploring more or all of the domains.
Nursing models and assessment in practice
Nursing models and assessment frameworks are tools that are designed to support the assessment process, and they should be easy to use.
Patient assessment is a complex skill—the ability to glean important information at the right time can take years. An assessment framework provides a useful prompt for the novice, to ensure no aspect of assessment is overlooked.
Interpersonal skills and assessment
Assessment is a ‘conversation with a purpose’ (Bates, 1999); like any social situation the participants need to feel at ease if they are to divulge intimate details of their lives.
A competent interviewer is able to instil an air of calm confidence and absolute professionalism. The interview will be structured and at times directional, but it should never feel rushed.
Preparation for nursing assessment
• Always introduce yourself—explain who you are and why you are there
• Obtain patient consent for assessment
• Provide explanation and reassurance
• Ensure privacy and dignity is protected
• Check whether the patient wants a relative or carer to contribute to the assessment
• Make sure the assessment is proportionate to need.
(See Chapter 22, ‘Communication’, for further information.)
History taking
The purpose of history taking is to place a person's current health status in the context of their previous medical, social, psychological, and spiritual experience. The goal of history taking is to understand what is wrong with the patient, so that choices in treatment and/or supportive care can be offered.
History taking is an opportunity to explore and manage a patient's fears and expectations of the consultation. All assessments should conclude with a summary of key issues—ratified by the patient—and an agreement about what happens next.
History taking must be structured to be effective, but it is not an inquisition! The patient must not feel under pressure. Remind other members of the team that if each person asks the same questions, over and over again, it is stressful and disorientating, and resembles techniques used by the military to interrogate prisoners!
A standard approach
The model used for history taking and documentation will depend on the presentation of the patient. The framework used for many older people with nursing or social care needs, will be the single or integrated assessment process.
For those presenting with an illness, an advanced nursing assessment using a medical model of history taking and examination may be appropriate. Experts will tailor their approach to the individual patient.
A standard approach to history taking for advanced nursing and medical assessments usually starts with the patient's story of the presenting illness or event that precipitated the assessment.
Once you have recorded the patient's story in their own words, you can investigate the following with a mixture of open and closed questions:
• Presenting symptoms/issues
• History of symptoms/issues
• General medical history/family medical history
• Medications
• Social history/support networks
• Activities of living
• Biometric measurements/systems review.
When documenting your findings in multidisciplinary or electronic care records, it is important to write a summary of your main findings, a record of discussions with the patient and their relatives, the action plan, including diagnostic tests ordered, referrals made, and any changes in treatment. The summary should clearly identify what is expected to happen next, when, by whom, and with what review.
Assessment tools in nursing: a framework for advanced nursing assessment
The level of assessment undertaken will depend upon patient need, and the knowledge and skill of the assessor. Specialist and advanced nursing assessments must only be undertaken by nurses who are trained and competent in the assessment techniques used (NMC, 2006).
The range and complexity of assessment is commensurate with experience, education, and role definition in nursing. This is demonstrated in Fig. 21.1.
Further information
Bickley, S., and Hoekelman, R. (Eds) (1999) Bates' Guide to Physical Examination and History Taking. Lippincott, Philadelphia.
Find This Resource
Nursing and Midwifery Council. (2006) Standards to support learning and assessment in practice, NMC. Available at: http://www.nmc-uk.org/aFrameDisplay.aspx?DocumentID=1878
Find This Resource
Wilson, K., Clegg, A., Fairclough, F., and Jones, S. (2005) Implementing the single assessment for older people. Nursing Times, 101, 32–43.
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Physical examination and assessment: a body systems approach
The key domains of physical assessment and the range of validated assessment tools that can support physical and psychological assessment are identified in Table 21.1.
Table 21.1 Physical assessment
Assessment | Note | Registered Nurse assessment | Advanced Practitioner assessment |
|---|---|---|---|
General appearance/general observations | How does the patient look, e.g. colour, mood, posture, consciousness (any sign of reduced conscious level, check airway and breathing, biometric readings and Glasgow Coma Scale) | Observation, assessment, action plan, record keeping and reporting | Observation, assessment, pattern recognition, action plan, record keeping and communication |
Patient perspective/presenting symptoms | Does the patient describe any symptoms? (Record in the patients own words) | Patient perception of the problem | Patient perception and description in terms of:
|
Biometric measurement tools in assessment | What do the biometric measurements tell you? Does the patient have signs of a pyrexia, brady/tachicardic, hypo/hypertension or breathlessness? | Temperature Pulse Respiration rate Blood pressure Pulse oxymetry | RN assessment plus consideration of other available biometric measurements e.g. ECG Blood Tests X-rays |
Neurological system | Is the patient fully conscious? Is there any facial droop or muscle weakness? Is there any alteration in speech, swallowing, vision, gait or balance? | Glasgow Coma Scale (GCS) Assessment of sight and hearing. Ability to stand and balance | GCS Cranial nerve examination Peripheral nerve examination of sensation, tone, power and reflexes Romberg test Pronator drift |
Respiratory System | Note any injury, cyanosis, wheeze, respiratory distress or sputum | Respiratory rate Pulse Oxymetry Peak flow measurement | Respiratory rate Pulse oxymetry Peak flow measurement Capillary refill time Inspect, palpate, percuss and auscultate chest, front and back comparing both sides |
Cardiovascular system | Note any ankle or sacral oedema Record any chest pain in detail including, severity, nature, duration and radiation | Pulse rate/rhythm Blood pressure | Pulse rate/rhythm Blood pressure in both arms ECG recording Assess jugular venous pressure Locate apex beat Auscultate heart in aortic, pulmonary, tricuspid and mitral area |
Skin and nails | Assess skin integrity, skin turgor, colour, and texture noting any lesions, rashes or bruises | Waterlow score Braden score | Waterlow score Braden score Inspect nails for clubbing, spooning, splinter haemorrhage or infection |
Gastrointestinal system | Assess oral health, swallowing, appetite, weight, bowel function noting changes in weight and or bowel function Ask about rectal bleeding or black stools Inspect mouth for signs of infection, lesions, dehydration, dental caries, inflammation, and anaemia | Record weight Record Body Mass Index (BMI see Appendix 3) Record altered bowel habit, consider Bristol Stool Chart, FOB | As RN plus:
|
Urinary system | Assess function in terms of frequency, volume, and colour of urine. Enquire if there is discomfort on micturition or incontinence. | Through test urine Mid-stream urine specimen if the patient is unwell with symptoms of a urinary tract infection. Continence assessment including history and continence diary. | As RN plus;
|
Musculoskeletal system | Assess range of movement; note any joint deformity and enquiring about joint pain. Record history of fractures and bony injury | Visual inspection of joints and history of joint pain/fractures. | Musculoskeletal examination including:
|
Mental health/communication and cognition | Does the patient respond appropriately to questions? Make eye contact? Appear depressed? Is there any indication of social isolation? | SAP (abbreviated depression and AMTS score see Appendix 2). | AMTS (see Appendix 1) MMSE HAD score |