REVIEW MANUAL
Source: The Royal Marsden Ninth Edition (Part 1)
NMC COMPUTER BASED TEST
(CBT)
CLINICAL NURSING PROCEDURES
ASSESSMENT AND DISCHARGE EVIDENCE-BASED APPROACHES
DATA COLLECTION
ASSESSMENT
- Is the process of gathering information about the patient‟s
- Is the systematic and continuous collection, organisation health needs. This information is collected by means of
validation and documentation of information (Berman et interview, observation and physical examination and consist
al. 2010). of both OBJECTIVE and SUBJECTIVE data.
- It is a deliberate and interactive process that underpins OBJECTIVE DATA
every aspect of nursing care (Heaven and Maguire 1996).
- Are measurable and can be detected by someone other
- It is the process by which the nurse and patient than the patient. They include vital signs, physical signs
together identify needs and concerns. It is seen as the and symptoms, and laboratory results.
corner-stone of individualised care, a way in which the
uniqueness of each patient can be recognised and SUBJECTIVE DATA
considered in the care process (Holt 1995).
- Are based on what the patient perceives and may include
PRINCIPLES OF ASSESSMENT descriptions of their concerns, support network, their
awareness and knowledge of their abilities/disabilities, their
1. Patient assessment is patient focused, being govern by understanding of their illness and attitude to and readiness 1
the notion of an individual‟s actual, potential and for learning (Wilkinson 2007).
perceived needs.
2. It provides baseline information on which to plan the Nurses working in different settings rely on different
interventions and outcomes of care to be achieved. observational and physical data. A variety of methods have
3. It facilitates evaluation of the care given and is a been developed to facilitate nurses in eliciting both objective
dimension of care that influences a patient‟s outcome and subjective assessment data on the assumption that, if
and potential survival. assessment is not accurate, all other nursing activity will also
4. It is a dynamic process that starts when problems or be inaccurate.
symptoms develop, and continues throughout the care
process, accommodating continual changes in the LEGAL AND PROFESSIONAL ISSUES
patient‟s condition and circumstances.
5. It is essentially an interactive processing which the NHS Knowledge and Skills Framework (DH 2004a)
patient actively participates.
6. Optimal functioning, quality of life and the promotion of - States that the specific dimensions of assessment and
independence should be primary concerned. care planning to meet people‟s health and wellbeing
7. The process include observation, data collection, clinical needs and assessment and treatment planning related
judgment and validation of perceptions. to the structure and function of physiological and
8. Data used for the assessment process are collected from psychological system are core to nursing posts in all
several sources by a variety of methods, depending on settings.
the healthcare setting. - Staff will need to be aware of their legal obligations and
9. To be effective, the process must be structured and responsibilities, the rights of the different people
clearly documented. involved, and the diversity of the people they are
working with.
- An effective assessment will provide the nurse with - Nurses have an obligation to record details of any
information on the patient‟s background, lifestyle, family assessments and reviews undertaken and provide clear
history and the presence of illness or injury (Crouch and evidence of the arrangements that have been made for
Meurier 2005). future and on-going care (NMC 2010). This should also
include details of information given about care and
- The nursing assessment should focus on the patient‟s treatment.
response to a health need rather than disease process
and pathology (Wilkinson 2007). POINTS FOR CONSIDERATION
The process of assessment requires nurses to make accurate 1. COGNITIVE AND PERCEPTUAL ABILITY
and relevant observations, to gather, validate and organise
data and to make judgments to determine care and COMMUNICATION
treatment needs. It should have physical, psychological,
spiritual, social and cultural dimensions, and it is vital that The nurses needs to assess the level of sensory functioning with
these are explore with the person being assessed. or without aids/support such as hearing aid(s), speech aid(s),
glasses/contact lenses, and the patient capacity to use and
The purpose of nursing assessment is to get a complete maintain aids/support correctly. Furthermore, it is important to
picture of the patient and how they can be helped. assess whether there are or might be any potential language or
cultural barriers during this part of assessment. Knowing the norm
within the culture will facilitate understanding and lessen
miscommunication (Galanti 2000).
, (POINTS FOR CONSIDERATION cont…..) 3. ELIMINATION
INFORMATION GASTROINTESTINAL
During this part of assessment, the nurse will assess the patient‟s During this part of the assessment it is important to determine a
to comprehend the present environment without showing level of baseline with regard to independence.
distress. This will help establish whether there are any barriers to • Is the patient able to attend to their elimination needs
the patients understanding their condition and treatment. It may independently and is he/she continent?
help them to be in a position to give informed consent. • What are patient‟s normal bowel habits?
• Are bowel movements within the patient‟s own normal
NEUROLOGICAL pattern and consistency?
• Does the patient have any underlying medical conditions
It is important to assess the patient‟s ability to reason logically and such as Crohn‟s disease or irritable bowel syndrome?
decisively, and determine that he or she is able to communicate in • How does this affect of patient?
a contextually coherent manner.
GENITOURINARY
PAIN
This assessment is focused on the patient‟s baseline observations with
To provide optimal patient care, the assessor needs to have regard to urinary continence/incontinence. It is also important to note
appropriate knowledge of the patient‟s pain and an ability to identify whether there is any penile or vaginal discharge or bleeding.
the pain type and location. Assessment of a patient‟s experience of
pain is crucial component in providing effective pain management. 4. NUTRITION
Dimond (2002) asserts that it is un acceptable for patients to ORAL CARE
experience unmanaged pain or for nurses to have inadequate
knowledge about pain. Pain should be measured using an As part of inpatient admission assessment, the nurse should obtain
assessment tool that identifies the quality and/or quality of one or an oral health history that include oral hygiene beliefs, practices
more of the dimensions of the patient‟s experience of pain. and current state of oral health. During this assessment it is
important to be aware of treatments and medications that affect
Australian and New Zealand College of Anaesthetists 2005, Jensen the oral health of the patient.
et al. 2003, Rowbotham and Macintyre 2003 2
Assessment should also observe for signs for neuropathic pain, HYDRATION
including descriptions such as shooting, burning, stabbing,
allodynia (pain associated with gentle touch). An in-depth assessment of hydration and nutritional status will provide
the information needed for nursing interventions aimed at maximising
2. ACTIVITY AND EXERCISE wellness and identifying problems for treatment. The assessment
should ascertain whether the patient has any difficulty eating or
RESPIRATORY drinking. During the assessment the nurse should observe signs of
dehydration, for example dry mouth, dry skin, thirst or whether the
Respiratory pattern monitoring addresses the patient‟s breathing patient shows any signs of altered mental state.
pattern, rate and depth.
NUTRITION
In this section it is also important to assess and monitor smoking
habits. It is helpful to document the smoking habit in the format of A detailed diet history provides insight into a patient‟s baseline
pack-years. A pack-year is a term used to describe the number of nutritional status. Assessment includes questions regarding
cigarettes a person has smoked over time. One pack- year is chewing or swallowing problems, avoidance of eating related to
defined 20 manufactured cigarettes (one-pack) smoked per day abdominal pain, changes in appetite, taste or intake, as well as
for 1 year. At this point in the assessment, it would be a good use of a special diet or nutritional supplements. A review of past
opportunity, if appropriate, to discuss smoking cessation. A recent medical history should identify any relevant conditions and
meta-analysis indicates that if interventions are given by nurses to highlight increased metabolic needs, altered gastrointestinal
their patients with regard to smoking cessation the benefits are function and the patient‟s capacity to absorb nutrients.
greater (Rice and Stead 2008).
NAUSEA AND VOMITING
CARDIOVASCULAR
During this part of assessment you want to ascertain whether the
A basic assessment is carried out and vital signs such as pulse patient has any history of nausea and/or vomiting. Nausea and
(rhythm, rate and intensity) and blood pressure should be noted. vomiting can cause dehydration, electrolyte imbalance and
Details of cardiac history should be taken for this part of the nutritional deficiencies (Marek 2003), and can also affect the
assessment. Medical conditions and experience of previous surgery patient‟s psychosocial well-being. They may become withdrawn,
should be noted. isolated and unable to perform their usual activities of daily living.
PHYSICAL ABILITIES, PERSONAL HYGIENE/ MOBILITY/ 5. SKIN
TOILETING, INDEPENDENCE WITH ACTIVITIES OF DAILY LIVING
A detailed assessment of a patient‟s skin may provide clues to
The aim during this part of assessment is to establish the level of diagnosis, management and nursing care of the existing problem.
assistance required by the person to tackle activities of daily living A careful skin assessment can alert the nurse to cutaneous probles
such as walking steps/stairs. An awareness of obstacles to safe as well as systematic diseases. In addition, a great deal can be
mobility and dangers to personal safety is an important factor and observed in a person‟s face, which may give insight to his or her
part of the assessment. state of mind.
The nurse should also evaluate the patient‟s ability to meet 6. CONTROLLING BODY TEMPERATURE
personal hygiene, including oral hygiene, needs. This should
include the patient‟s ability to make arrangements to preserve This assessment is carried out to establish baseline temperature and
standards of hygiene and the ability to dress appropriately for determine if the temperature is within normal range, and whether
climate, environment and their owned standard of self-identity. there might be intrinsic factors for altered body temperature.
