Cover: Fundamentals of Assessment and Care Planning for Nurses by Ian Peate OBE, FRCN

Fundamentals of Assessment and Care Planning for Nurses

IAN PEATE, OBE, FRCN

Head of School, School of Health Studies
Visiting Professor of Nursing, St George's University of London, Kingston University London
Editor in Chief, British Journal of Nursing
Visiting Senior Clinical Fellow, University of Hertfordshire
University of Gibraltar







No alt text required.

Preface

The Fundamentals of Assessment and Care Planning for Nurses has been written to help develop the assessment and care planning skills of the nurse. In order to assess needs effectively in a patient‐centred way the nurse is required to have a detailed understanding of the nursing process and the skills needed to plan care that is individual and holistic. Assessment and care planning are set against a backdrop of a dynamic and changing nursing profession as well as how contemporary care is being provided (Chapters 1 and 2).

The initial nursing assessment, the first step in the five steps of the nursing process, demands the systematic and continuous collection of data. Chapter 4 provides details concerning the systematic, cyclical nature of the nursing process. The nurse is required to systematically organise and analyse the data that has been gathered. Once primary and secondary data have been gathered there is a need to document and communicate findings in a care plan (Chapter 5) so that care can be delivered in response to an individual’s unique sociocultural and physical needs, incorporating evidence‐based practice.

Using the nursing process effectively demands the application of critical thinking skills that have been applied during the various phases of the nursing process. Critical thinking skills and the decision‐making process feature in Chapter 3. The nursing process is a decision‐making framework that helps the nurse work with the patient where appropriate. The use of a nursing model (Chapter 6) can help develop and steer the plan of care.

During nursing assessment information is gathered regarding the patient’s individual physiological, psychological, sociological, and spiritual needs. This phase is the first phase required for the successful evaluation of care interventions. Working in partnership with the patient, the nurse collects subjective and objective data throughout the nursing process, the skills needed to do this are outlined in Chapter 7.

The Fundamentals of Assessment and Care Planning for Nurses discusses the general and focussed assessment of needs in relation to the body systems. There are a variety of assessment tools that are available to help the nurse in the assessment phase (see Chapter 8).

The first eight chapters of Fundamentals of Assessment and Care Planning for Nurses provide the foundations needed to be able to assess, make a diagnosis, plan care, implement that care, and devise strategies to evaluate outcomes. The nature of nursing offers insight into contemporary health and social care provision. Emphasis is placed on how care provision is dynamic and the voice of the service user is the key driver in how nurses and care providers respond to needs.

Key to understanding the primary and secondary source data that has been collected when assessing needs is the application of critical thinking and clinical decision making in order to formulate a plan of care. The skills and attributes of a critical thinker are outlined as the nurse applies the five phases of the nursing process and the planning of individual care plans using a model of nursing to steer and guide data collection.

The initial nursing assessment is a key component of nursing practice, it begins the nursing process. The use of assessment tools can, when appropriate and when utilised correctly, yield objective data, this is then used to implement care and evaluate impact. There are many assessment tools available and their content varies, they aim to help the nurse provide safe and evidence‐based care. Assessment tools are described in Chapter 8.

The Nursing and Midwifery Council’s (NMC) (2018a) Code is clear when it states that the nurse must ensure that people’s physical, social, and psychological needs are assessed and responded to. In order to demonstrate compliance with this clause the nurse must undertake a comprehensive and systematic nursing assessment, plan nursing care in partnership with the patient and respond in an effective way to changing needs and changing situations.

There are 12 chapters of Fundamentals of Assessment and Care Planning for Nurses dedicated to the assessment of body systems. Each of these chapters begin with a discussion of the anatomy and physiology of the body system. Within these chapters the reader is provided with information and understanding associated with the gathering of subjective and objective data as the nurse conducts a health history interview and performs a physical examination. A practical approach is adopted, urging the nurse to learn the art and science associated with assessment to develop and hone their skills.

This text is timely as the NMC introduces its new Standards of Proficiency for Nurses (NMC 2018b). The proficiencies specify the knowledge and skills that registered nurses must demonstrate when caring for people, these are the proficiencies that the nurse must have met prior to being allowed entry on to the professional register as they gain their licence to practise. Within these new standards, platforms three and four focus on assessing needs and planning care; and providing and evaluating care (respectively).

Those who provide nurse education are required to develop and deliver programmes that give nurses the skills, knowledge and behaviours they need. The NMC’s new Standards for Pre‐registration Nursing set out how they must do this (NMC 2018c). The Fundamentals of Assessment and Care Planning for Nurses echo many of the requirements around assessing needs and planning care, providing and evaluating care.

There have been further developments in the profession as the NMC have also produced standards that outline the proficiencies for Nursing Associates (NMC 2018d) along with the Standards for Pre‐registration Nursing Associate Programmes (NMC 2018e). The nursing associate is required to provide compassionate care and contribute to on‐going assessment, recognising when needed to refer to others for reassessment.

Each chapter begins with an aim and learning outcomes, enabling the reader to contextualise and focus on the chapter content and the NMC proficiencies. The Fundamentals of Assessment and Care Planning for Nurses adopts a practical approach in order to facilitate learning, apply theory to practice, and encourage a person‐centred approach, and to aid recall, a number of features and activities have been incorporated to assist with this. The book is fully illustrated throughout with clear artwork. There are a number of interactive learning features, encouraging the reader to review their learning, take note of key issues, and engage with the various elements associated with the 6Cs. Where appropriate the reader is drawn to cultural considerations where there are specific issues that have to be given due consideration. A fictitious family, the Samudas, is introduced to help link further the assessment of needs, focusing on the individual needs of a family member and the family unit. The chapters have several summary sections interspaced, enabling the reader to digest the bite‐sized theory.

There are a number of mnemonics used throughout the book. Their inclusion is to assist and promote comprehensive history taking and a systematic, focused physical assessment. The mnemonics, however, should not be viewed simply as tick boxes, but rather as a way of triggering the nurse during history taking and examination addressing areas of importance.

I have very much enjoyed writing Fundamentals of Assessment and Care Planning for Nurses, it comes at an interesting time for nurses, the nursing profession, and those who work with us, as we are experiencing much change within and without the profession. My intention has been to help you understand, to apply what it is you are reading as you offer care to people (often the most vulnerable in society), to whet your appetite and inspire you to delve deeper and to stimulate curiosity, but most of all to ensure that the patient is truly at the heart of all you do.

References

  1. Nursing and Midwifery Council (2018a). The Code. Professional standards of practice and behaviour for nurses, midwives and nursing associates. www.nmc.org.uk/globalassets/sitedocuments/nmc‐publications/nmc‐code.pdf last accessed October 2018.
  2. Nursing and Midwifery Council (2018b). Standards of proficiency for registered nurses. www.nmc.org.uk/globalassets/sitedocuments/education‐standards/future‐nurse‐proficiencies.pdf last accessed October 2018.
  3. Nursing and Midwifery Council (2018c). Standards of pre‐registration nursing programmes. www.nmc.org.uk/globalassets/sitedocuments/education‐standards/programme‐standards‐nursing.pdf last accessed October 2018.
  4. Nursing and Midwifery Council (2018d). Standards of proficiency for nursing associates. www.nmc.org.uk/globalassets/sitedocuments/education‐standards/nursing‐associates‐proficiency‐standards.pdf Last accessed October 2018.
  5. Nursing and Midwifery Council (2018e). Standards for pre‐registration nursing associate programmes. www.nmc.org.uk/globalassets/sitedocuments/education‐standards/nursing‐associates‐programme‐standards.pdf Last accessed October 2018.

Acknowledgements

I would like to thank my partner Jussi Lahtinen, who continues to encourage and support me. I acknowledge my gratitude to my friend Mrs Frances Cohen. I owe thanks to my brother Anthony Peate, who helped with the illustrations. Thank you to the library staff at Gibraltar Health Authority and the Royal College of Nursing. Special thanks to Magenta Styles at Wiley – your enthusiasm is palpable.

Meet the family

One of the features used in Fundamentals of Assessment and Care Planning for Nurses centres around a fictitious family, the Samudas (all names and details are fictional in accordance with the Nursing and Midwifery Council’s (2018) Code). Inclusion of the family helps to provide context to the chapters that focus on assessment of the body systems. In each of these chapters a family member is discussed and the reader is encouraged to consider that individual family member’s needs as well as how their condition may impact on the family unit.

The Samuda family live in a small town on the South West coast, all within walking distance of each other apart from Howard, who lives in Norwich. The Samudas live in a housing complex in Welltown south of the river. They own a four‐bedroomed semi‐detached house.

You will meet various members of the Samuda family in several chapters of the book. There are nine members of the Samuda family, take some time to get to know them (see the genogram in Figure 1).

Genogram displaying Bob Coleman and Ruby Coleman branching to Shahine Samuda and Judith Higgins. Shahine Samuda branches to Maurice, Howard, Kamina, etc. Judith Higgins branches to Winston and Tamika Higgins.

Figure 1 Genogram.

Ruby Coleman 70 years old (grandmother). Ruby lives in the same street as the Samuda family and offers her daughter support with the family when she can. Ruby is a member of the local bridge club and enjoys watching the soaps. She enjoys baking.

Bob Coleman, 74 years old (grandfather). Bob lives in the same street as the Samuda family. Bob meets up with his mates, with whom he worked on the railway. He finds getting around a little more difficult now as he has been getting ‘caught short’ once too often lately.

Shahine Samuda Mother: 39 years old, part‐time ward clerk. Shahine spends most her time when not working looking after the family. She likes to swim. Shahine and her best friend Marie also like to dance, they are learning to salsa.

Maurice Samuda Father: 44 years old, is a full‐time civil servant. Maurice spends most his free time fixing up old motor bikes in his shed, he gets little physical exercise. He is overweight, smokes 60 cigarettes a week. Maurice drinks alcohol to excess.

Howard Samuda Son: 23 years old, works full time in a law firm. Howard lives in Norwich, left home six years ago after a disagreement with his father. He keeps in touch with the family via Kam. Howard is an avid traveller and is studying part‐time for a Master’s degree in Law.

Kamina (Kam) Samuda Daughter: 17 years old, student at Goodenough School and is about to undergo her A levels. Kam has found being at home recently a little overwhelming at times; she tends to spend her time at her boyfriend’s house, where she says it is much a calmer. Kam wants to go to university and study electrical engineering; she is studying hard at school.

Oswald (Ossie) Samuda Son: 13 years old with special needs, student also attending Goodenough School. Ossie is the youngest child. He uses a wheelchair for mobility and he has a special education needs teacher who supports him at school. Shahine is Ossie’s main carer. Ossie enjoys swimming and playing on his PlayStation.

Judith Higgins (Daughter of Ruby and Bob): 45 years old (Aunty Judy). Judith lives in close proximity to the Samudas and the Colemans. Judy has not worked for the last five years. Judy and her husband Winston are close to the family. They have no children. However, her niece, Shahine, has expressed concerns about Judith’s cognitive state.

Winston Higgins (Son in law of Ruby and Bob): 43 years (Uncle Winston). Winston lives in close proximity to the Samudas and the Colemans. He enjoys cycling and hiking in the highlands whenever he can get a chance, he is a postman. Winston lives with Judith. He is becoming more and more a key carer of Judith, who he says has become very short‐tempered and even more forgetful.

Reference

  1. Nursing and Midwifery Council (2018) The Code. Professional standards of practice for nurses, midwives and nursing associates. www.nmc.org.uk/globalassets/sitedocuments/nmc‐publications/nmc‐code.pdf last accessed October 2018.