Chapter 2: Admissions and assessment
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Source: Adapted from Alfaro‐LeFevre ([3]), NMC ([55]), Teytelman ([83]), White ([90]).
Source: Adapted from Gordon ([34]) with permission of Mosby / Elsevier.
Related theory
Nurses perform assessments on patients to inform professional judgements on what care is required. Assessment takes place from the time a nurse encounters the patient and is ongoing, continuing until discharge from the nurse's care. Nurses use various tools to facilitate the process of assessment (Crouch and Meurier [17]).
A health assessment involves the collection and analysis of data in order to identify the patient's problems. The nursing health assessment incorporates a comprehensive health history and a complete physical examination, both of which are used to evaluate the health status of a person; it is a deliberate and interactive process. The need to solicit information, understand the findings and apply knowledge can initially be daunting to the new nurse. Regardless of who collects the data, a total health assessment is needed when a patient first enters the healthcare system.
The nursing assessment should focus on the patient's response to a health need rather than disease process and pathology (Wilkinson [91]). The process of assessment requires nurses to make accurate and relevant observations and to gather, validate and organize data; this process supports the nurse in making judgements to determine care and treatment needs. The nursing assessment should include physical, psychological, spiritual, social and cultural dimensions; it is vital that these dimensions are explored with the person being assessed.
Effective patient assessment is integral to the safety, continuity and quality of patient care. The main principles of assessment fulfil the nurse's legal and professional obligations in practice (Table 2.2).
Table 2.2 Principles of assessment
| 1 | Assessment is patient focused, being governed by the notion of an individual's actual, potential and perceived needs. |
| 2 | It provides baseline information from which to plan the interventions to be used and decide the outcomes of care to be achieved. |
| 3 | It facilitates evaluation of the care given and is a dimension of care that influences a patient's outcome and potential survival. |
| 4 | It is a dynamic process that starts when problems or symptoms develop and continues throughout the care process, accommodating continual changes in the patient's condition and circumstances. |
| 5 | It is an interactive process in which the patient actively participates. |
| 6 | Optimal functioning, quality of life and the promotion of independence should be primary concerns. |
| 7 | The process includes observation, data collection, clinical judgement and validation of perceptions. |
| 8 | Data used for the assessment process are collected from several sources by a variety of methods, depending on the healthcare setting. |
| 9 | To be effective, the process must be structured and clearly documented. |
Assessment tools
Assessment tools in clinical practice can be used to assess a patient's general needs – for example, via the Supportive Care Needs Survey (Bonevski et al. [10]) – or to assess a specific problem – for example, via the Oral Assessment Guide (Eilers et al. [26]). The choice of tool depends on the clinical setting, although, in general, the aim of using an assessment tool is to link the assessment of clinical variables with the measurement of clinical interventions (Frank‐Stromborg and Olsen [30]). To be useful in clinical practice, an assessment tool must be simple and acceptable to patients, have a clear and interpretable scoring system, and demonstrate reliability and validity (Brown et al. [11]).
The use of patient self‐assessment tools appears to facilitate the process of assessment in a number of ways. It enables patients to indicate their subjective experience more easily, gives them an increased sense of participation (Kearney [44]) and prevents them from being distanced from the process by nurses rating their symptoms and concerns (Brown et al. [11]). Many authors have demonstrated the advantages of increasing patient participation in assessment by the use of patient self‐assessment questionnaires (Rhodes et al. [68]).
The methods used to facilitate patient assessment are important adjuncts to assessing patients in clinical practice. There is a danger that too much focus can be placed on the framework, system or tool, preventing nurses from thinking about the significance of the information that they are gathering from the patient (Harris et al. [36]). Rather than following assessment structures and prompts rigidly, it is essential that nurses utilize their critical thinking and clinical judgement throughout the process in order to continually develop their skills in eliciting information about patients’ concerns and use this to inform care planning (Edwards and Miller [25]).
Structure of assessment
Structuring patient assessment is vital to monitoring the success of care and detecting the emergence of new problems. There are many conceptual frameworks or nursing models, such as Roper's model for assessing activities of daily living (Roper et al. [70]), Orem's self‐care model (Orem et al. [57]) and Gordon's functional health patterns framework (Gordon, [34]). There remains, however, much debate about the effectiveness of such models for assessment in practice, with some arguing that individualized care can be compromised by fitting patients into a rigid or complex structure (Kearney [44], McCrae [48]). Nurses therefore need to take a pragmatic approach and utilize assessment frameworks that are appropriate to their particular area of practice. This is particularly relevant in today's rapidly changing healthcare climate, where nurses are taking on increasingly advanced roles, working across boundaries and setting up new services to meet patients’ needs (DH [20]).
The framework of choice at The Royal Marsden NHS Foundation Trust is based on Gordon's functional health patterns framework (Box 2.1; Gordon [34]). This framework facilitates an assessment that focuses on patients’ and families’ problems and functional status; the framework applies clinical cues to interpret deviations from the patient's usual patterns (Johnson [43]). Gordon's functional health patterns framework is applicable to all levels of care, allowing problem areas to be identified. Information derived from the patient's initial functional health patterns is crucial for interpreting both the patient's and their family's pattern of response to disease and treatment.
Box 2.1
Gordon's functional health patterns
- Health perception and health management
- Nutrition and metabolism
- Elimination
- Activity and exercise
- Sleep and rest
- Cognition and perception
- Self‐perception and self‐concept
- Coping and stress tolerance
- Roles and relationships
- Sexuality and reproductivity
- Values and beliefs
Types of patient assessment
There are several types of assessment, including mini assessment, comprehensive assessment, focused assessment and ongoing assessment (Box 2.2).
Box 2.2
Types of patient assessment
Mini assessment
A snapshot view of the patient based on a quick visual and physical assessment. Consider the patient's ABC (airway, breathing and circulation), then assess mental status, overall appearance, level of consciousness and vital signs before focusing on the patient's main problem.
Comprehensive assessment
An in‐depth assessment of the patient's health status, risk factors, and psychological and social aspects of health, along with a physical examination; it usually takes place on admission or transfer to a hospital or healthcare agency. It also considers the patient's health status prior to admission.
Focused assessment
An assessment of a specific condition, problem, identified risk or care need – for example, continence assessment, nutritional assessment, neurological assessment following a head injury, assessment for day care or outpatient consultation for a specific condition.
