The Holistic Patient Assessment Essay Paper.
Understanding the Assessment Process
1. Assessment:
It is the dynamic and continuous process of collecting, verifying, and organizing
information about a person within a particular context. The process starts with the
first nurse-patient encounter and continues throughout the nurse-patient relationship.
Emphasis is on health status, environment, strengths and limitations as well as on the
person’s cultural beliefs and practices. The Holistic Patient Assessment Essay Paper.Assessment yields an individualized patient
database from which the nurse identifies the status of actual or potential limitations
and strengths; collaborates and contributes to the plan of care and reviews and
interprets the plan of care; makes decisions regarding the selection and
implementation of appropriate nursing interventions based on the plan of care;
intervenes; evaluates by monitoring and recognizing changes in patient status in
response to interventions; reports and records with a view to assist the patient to
achieve or to maintain optimal health. Assessment is a deliberate and/or incidental
activity.
An example of the process described would occur when the LPN determines a
patient’s blood pressure is low prior to the next scheduled dose of antihypertensive
medication. The licensed practical nurse knows that administering an
anti hypertensive at this time may compromise the patient and decides to withhold the
medication. The nurse documents the findings and informs and consults with the
registered nurse or other appropriate healthcare provider.
2. Sources of data:
a. Background nursing knowledge obtained from multiple and varied sources.
Knowledge helps the nurse
i. determine the information to seek in a given situation
ii. differentiate relevant and irrelevant data
iii. prioritize data
iv. recognize data needing to be verified and/or clarified
v. facilitate systematic organization of data
vi. analyze data based on a set of norms
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b. Clinical record: medical history, current medical problems and interventions,
laboratory values and results of other diagnostic tests, previous assessments,
and information from other healthcare providers.
c. General observation of the patient, environment and interpersonal interactions.
d. A health history/interview accompanies the physical assessment. Typically
health history includes biographic data, current health problems, past health
history, family history of health challenges, current medication and
treatments, allergies, personal social history (role and relationship patterns),
cultural beliefs and practices related to health (health promotion with attention
to exercise, diet; protection patterns such as avoiding unintentional injuries;
and prevention evident with immunization compliance), review of systems
and in particular noting activities of daily living and advanced directives.
The information from the interview facilitates
i. a focus for the assessment and helps identify patient expectations and
concerns, and offers the patient’s perspective and meaning of the data
ii. identification of strengths and limitations to guide the planning of
nursing care. The Holistic Patient Assessment Essay Paper.
e. Physical assessment includes 4 basic techniques: inspection (look), palpation
(touch), percussion (tap) and auscultation (listen) (IPPA). To enhance
proficiency of assessment use the order of IPPA except when carrying out an
abdominal assessment
i. the patient may be asked to demonstrate certain activities such as
walking, bending, detection of noises, speaking, smells and reading a
visual acuity chart
f. Assessment further includes the use of diagnostic tests such as laboratory
tests, pathology reports, radiographs, electrocardiograms, etc.
g. Consultations: family and friends provide data about the patient’s usual
behaviour patterns and coping mechanisms, recent changes in health status
including cognitive and psychosocial changes, available resources, support
system, and additional concerns the patient may not have expressed. Other
sources include paraprofessionals who may have interacted with the patient.
3. Domains to be assessed: The Holistic Patient Assessment Essay.
The domains are interdependent and contribute to the development of a holistic
picture. The domains include
a. Physiologic: biological, physical, and functional characteristics.
b. Psychologic: emotional and cognitive features.
c. Social: dynamics of interpersonal relationships with individuals and groups.
d. Cultural: primary language, shared beliefs, perceptions and practices based on
common heritage or ethnic and/or racial background.
e. Spiritual: beliefs and values that provide strength, hope and meaning to life;
religious tenets and practices.
f. Developmental: evolutionary process over time from maturation, experience
or learning.
4. Types of data:
Data is classified as subjective and objective.
a. Subjective: what the person tells the assessor (i.e. description of pain,
perceptions, feelings or experiences).
b. Objective: evident, measurable, and verifiable observations such as vital
signs, odours, redness of a wound, hostile behaviour, and laboratory and
medical imaging findings.
c. Correlation of subjective and objective data: e.g. is shortness of breath
supported by decreased breath sounds on auscultation or dullness to
percussion?
5. Purpose of assessment:
The purpose is to plan care by identifying health care needs. Such identification may
include
a. Health promotion needs: enhance well being, preventative interventions.
b. Health risk factors
- Non modifiable risk factors i.e. biological, congenital, hereditary.
- Modifiable risk factors i.e. diet, smoking, and sedentary lifestyle.
c. Potential/risk health problems e.g. person with traumatic wound is at risk for
infection.
d. Actual health problems to direct action aimed at regaining or facilitating
optimal health.
6. Types of assessments:
For the purpose of this resource, assessments are classified as:
comprehensive/full,
quick priority, and
focused
a. Comprehensive assessment occurs when an individual is admitted to a health
care/residential setting and at individually determined intervals during a
continuing patient-health care provider relationship (i.e. anytime a baseline or
re-assessment is indicated). Specific responsibilities are outlined in the
practice expectations document.
b. Quick priority assessment is one that is carried out efficiently when a rapid
assessment is in order to familiarize oneself with the assigned patient such as
at shift change, with a change of patient assignment or temporarily assuming
care of a patient, and or a validation of patient status. A mnemonic ABC I/O
PS is a useful trigger to recall the technique.
19
A: AIRWAY:
Ensure airway is patent and protected, for example, not compromised by
position, supports, etc.
Can the patient speak?
B: BREATHING:
Determine the ease/effort and rate.
C: CIRCULATION:
Assess tissue perfusion by checking pulses, skin temperature and
color of the extremities.
Is edema present?
Determine the level of consciousness and orientation.
I: IN:
What is going in? Verify the identity of every substance entering the
patient and the operation/function of the device used for substance
delivery. Such checks include power source, electronic settings
controlling flow rates and pressure settings.
What is the condition of tissue surrounding the ports of substance
entry? The Holistic Patient Assessment Essay.
Ensure tubing/delivery devices are free of twists, kinks, obstructions, and
tension. Follow the source of substance delivery to its point of entry.
O: OUT:
What is coming out? What is the character and amount of drainage from
wounds, tubes, and body orifices?
Check dressings, drainage tubes, and devices, condition of ports of exit.
Do they need reinforcement, repositioning, emptying?
P: PAIN and overall comfort level:
Have the patient identify and describe pain using a pain scale.
What factors relieve/aggravate the pain?
Consider pain in the context of last analgesic/intervention.
Verify patient comfort such as related to position, temperature, anxiety,
and stress.
S: SAFETY:
Assess the environment. Are suction and oxygen delivery systems
functional and ready for use? Is the bed in a low position? Are
bed/wheelchair brakes engaged? Are restraints used according to
protocol and policy? Is the call bell accessible? Are personal items
within reach?
Conclude the quick priority assessment with a focused assessment related to the
patient’s health challenge. For example, for a patient with total hip replacement,
complete the following: check position of abductor pillows, are dressings intact,
determine character and amount of drainage on dressing/bedding, is drainage
device functioning and amount and character of drainage in the receptacle,
neuro vascular check, pain level assessment, nausea, etc.
c. Focused assessment addresses a particular problem or issue and may be done
in response to
i. changing health status that precludes a full assessment e.g. acute pain
or respiratory distress
ii. presentation of an episodic problem such as a sore throat
iii. the need to determine progress of a specific potential or actual health
problem
iv. the need to determine the effectiveness of an intervention e.g. relief of
pain by position change and/or medication
v. the assumption of care by a new care provider e.g. at the beginning of
a shift
Quick priority and/or focused assessments are used more often than a
comprehensive assessment. The findings of the more abbreviated assessment(s)
may determine the need for a comprehensive assessment.
7. Process of data collection:
Data is systematically gathered and organized. The process is guided by a structure
based on a variety of approaches. Some recognized approaches include
a. Physiologic: body systems approach that is sometimes referred to as a
medical model or a head-to-toe assessment.
b. Functional health patterns: identification of behavioural health patterns over
time which facilitates recognition of functional and dysfunctional patterns.
c. Needs models based on Maslow’s hierarchy of needs. For a review of
Maslow’s hierarchy click on the link below.
- http://web.utk.edu/~gwynne/maslow.HTM
d. Prescribed agency driven formats which are generally an adaptation or hybrid
of various models.
8. Context of data collection:
Ensure that you consider individual variations that may impact data collection and
subsequently influence interpretation of that data. Such variations include
growth and development
concurrent health challenges
culture and race
medications
Benchmark - Policy Brief Assignment.
9. What to do with the data:
The assessor should record data throughout the assessment followed by formal
documentation in an organized framework using correct terminology. Organizing data
may reveal a fit of data in more than one body system. Select the most appropriate
system/category and place it there. For example, getting up to the bathroom four
times a night may be relevant to renal system (urinary pattern) or musculoskeletal
system (sleep-rest activity pattern). Ensure that documentation clearly identifies
objective and subjective data. The process continues with
a. Comparative analysis of data
i. compare data with standards and norms. A standard or norm is a
generally accepted value, model or pattern. Examples include normal
lab data, growth and developmental stages, normal vital sign
parameters, cultural norms for behaviour, and usual symptom patterns
for a specific health problem
ii. identify which data match the norm and which vary
iii. compare data to what is normal for the patient
iv. begin to determine which data are relevant and which are irrelevant
b. Making and validating inferences
· Inferences are the process of assigning meaning to data.
· As soon as possible, inferences need to be validated with the person e.g.
are you feeling anxious? The Holistic Patient Assessment Essay.
c. Developing clusters of related data.
· The goal is to identify patterns.
· The inductive approach (reasoning from specific observations to general
statements) within a category and from different categories to form
patterns.
· The ability to recognize patterns is directly related to the nurse’s theoretical
knowledge base, clinical experience and general life experience.
· Identify and obtain missing data that may become known while trying to
identify patterns.
· Identify inconsistent data as they relate to patterns formulated.
· Determine a list of health care strengths and limitations.
Based on the cluster of data, formulate a list of identified actual and potential problems
with associated etiology. For example, impaired skin integrity related to immobility.
Identification of the problem forms the basis for planning individualized patient care
aimed at maintaining/optimizing health.
LPN Approach to Patient Assessment
Adequate preparation is essential to enhance patient and nurse comfort facilitating
execution of a thorough and competent assessment. The assessment includes the
interview; therefore the nurse must use effective communication strategies throughout the
procedure. An assessment may elicit a variety of patient responses. Benchmark - Policy Brief Assignment.These could include
fear, anxiety, and/or discomfort. Some patients may consider the process an invasion of
their privacy. Thus the nurse’s competency impacts the process and outcome.
Proficiency and expertise are gained with a systematic approach and practice.
Preparation:
- Ensure a well-lit environment that is conducive to carrying out a safe and
competent assessment that includes the health history/interview.
- Allow sufficient time to carry out the assessment.
- Organize self with necessary equipment, as appropriate
Watch with a second hand Marking pencil
Thermometer Scale
Stethoscope Tongue depressor
Sphygmomanometer Safety pin – sharp/dull assessment
Pulse oximeter Cotton ball – fine/light touch
Penlight/flashlight
Measuring tape
Specialized equipment based on
context of practice
Pocket ruler
- Attend to patient’s basic needs for safety, comfort such as pain management,
elimination needs, warmth, etc.; privacy and dignity. Maintain patient
comfort throughout the assessment.
- Introduce self, explain the process, and make general observations about
appearance, body features, state of consciousness and arousal, speech, body
movements, obvious physical signs, nutritional status, and behaviour.
- Determine patient’s ability to communicate since a family member,
interpreter or aids may be necessary to competently carry out the assessment.
- Assess whether variables such as the effect of a recently administered
medication may interfere with the accuracy and validity of the assessment.
- Be sensitive, unhurried and reassuring. Verify patient’s comfort with
proceeding e.g. a brief rest period may be necessary.
- Avoid negative and judgmental reactions in response to unexpected findings.
The use of empathy and acceptance are vital to forming a therapeutic nursepatient relationship that starts with the initial interaction. The Holistic Patient Assessment Essay.
- Wash hands prior to commencing the assessment.
- Always use the same systematic approach to facilitate a comprehensive
assessment with minimal repositioning of the patient.
- PQRSTA is an acronym describing one framework that is useful in gathering
data about any complaint/problem/symptom the patient may reveal or that the
nurse observes. Examples of such concerns include pain, shortness of breath,
fatigue, etc.
PQRSTA represents the following
3 Provocative or Palliative – What causes the symptom? What
makes is better or worse? What have you done to get relief?
3 Quality or Quantity – What is the character of the symptom i.e.
pain: is it crushing, piercing, dull, sharp? How much of it are you
experiencing now?
3 Region or Radiation – Where is the symptom? Does it spread?
3 Severity – How does the symptom rate on a severity scale of 1 to
10 with 10 being the most intense?
3 Timing – When did the symptom begin? How long does it last?
How often does it occur? Is it sudden or gradual?
3 Associated signs and symptoms of the chief complaint – Does the
primary problem result in any other clinical manifestations, e.g. the
pain accompanied by diaphoresis, nausea, vomiting?
OVERVIEW OF A PATIENT ASSESSMENT
As identified, a comprehensive assessment includes multiple components. This includes
gathering information from a health history, carrying out a general survey, measuring
vital signs, and assessing the body systems and psychosocial domain. The quality and
thoroughness of the assessment is strongly linked to the nurse’s competency in
assessment and knowledge of the patient’s present and past health challenges. Knowledge
of normal body function (physiological and psychological) is fundamental to carrying out
a comprehensive assessment. Therefore a body system overview is presented prior to the
corresponding detailed assessments for each of the domains. As indicated previously, the
practitioner’s comfort level assessing the systems will vary based on context of practice,
range of competencies, frequency of completing assessments, and type of assessments
regularly completed.
GENERAL SURVEY
This is the first impression of the patient that provides vital information about the
patient’s behaviour and health status. First observation must include airway, breathing
and circulation (ABC) assessment. Further initial impressions are made at this time that
include apparent age, gender, ethnicity, race, height, weight, nutritional status,
development, body type, posture, movements, aids, prosthetics, speech, dress, grooming,
personal hygiene, and signs of distress, facial characteristics, presence of family or
significant other(s) and psychological state.
Ask about the patient’s perception of their health.
Description of their health (usual, current), preventative measures,
previous hospitalizations & expectations of current experience,
description of illness (onset, cause), prior treatment (including
compliance, anticipated self-care problems).
Proceed with an organized systematic data collection to ensure all the elements of
assessment that follow are explored with the patient and/or family/friends, as appropriate.
Over time a nurse develops her/his own systematic approach to assessment. Consistency
in a systematic approach can be gained with the use of a head-to-toe framework and
IPPA. IPPA is the conventional approach with the exception of the abdominal
assessment. Make certain confidentiality is always maintained and that you have the
patient’s permission to gather data from a designate.
Note that in several sections, repetition and overlap of data collection occurs.
This ensures particular elements are considered in the event a focused
assessment precludes a comprehensive assessment. A detailed assessment
does not follow the endocrine system since this system is highly integrated with
other body systems. Relevant data is gathered while carrying out other
interdependent systems.
VITAL SIGNS
· Temperature
· Pulse (rate, rhythm, strength-quality)
· Respirations (rate, rhythm, depth)
· Blood pressure – supine, sitting, standing, right and left arms
· Pulse oximeter
The Holistic Patient Assessment Essay.
People with cancer require supportive and palliative care at different stages of the
patient pathway from a range of service providers in the community, hospitals,
hospices, care homes and community hospitals.
Supportive Care is defined by the National Council for Palliative Care:
‘…Supportive Care helps the patient and their family to cope with cancer and
treatment of it – from pre-diagnosis, through the process of diagnosis and treatment,
to cure, continuing illness or death and into bereavement. It helps the patient to
maximise the benefits of treatment and to live as well as possible with the effects of
the disease. It is given equal priority alongside diagnosis and treatment.’1
NICE Improving Outcome Guidance for Supportive and Palliative Care for Adults with
Cancer (2004) identified that there are a series of points on the patient pathway
where a patient may have particular or greater supportive care needs and
recommends that at these key points the patient should be offered a holistic
assessment (2). These points occur generally when there is a significant change in
diagnosis, treatment, condition, prognosis or the carer’s ability to cope. (3)
Key points are:
1. At or around the time of diagnosis (this may include circumstances in which
supportive care needs are manifest before diagnosis and particularly where
the process of investigation is protracted)
2. Commencement of treatment
3. Completion of the primary treatment plan
4. At each new episode of disease recurrence
5. At any other time that the patient may request
6. At any other time that the professional carer may judge necessary
7. The point of recognition of incurability (in some cases this may precede death
by years)
8. The beginning of end of life (in most cases this precedes death by less than
one year)
9. The point at which dying is diagnosed
Points 7 to 9 can be more difficult to determine and are heavily reliant on professional
judgement in recognising these points.
In respect of ‘end of life’ the Gold Standards Framework Team has developed a set
of prognostic indicators that may help professionals decide when it begins.
Three triggers are suggested:
• The Surprise Question – Would you be surprised if this patient were to die in
the next 6-12 months?
• Patient Choice – The patient with advanced disease makes a choice for
comfort care only (not curative treatment)
• Patient Need – The patient is in special need of supportive or palliative care
• Clinical Indicators – General predictors of end stage illness (5)
The Liverpool Care of the Dying Pathway documentation provides guidance
information for healthcare professionals about recognising dying and the key
indicators to identify when to place a dying patient on the pathway.(6)
Cancer patients may not be offered or have access to a holistic assessment at the
key points of need outlined and this affect whether they receive appropriate and
timely care.. There are broadly four distinct barriers to the provision of services for
patients and carers.
1. Needs may not be met because they are not recognised either by healthcare
professionals or by patients themselves
2. The relevant services may not be available because they had not been
planned or funded
3. The relevant services may exist but not be accessed because key
professionals are unaware of them
4. The relevant services may fail to bring maximum benefit because of poor
communication and coordination.
There are a number of assessment tools currently being used by various health and
social care professionals (eg: FACE and single assessment) but as yet these tools
do not cover all the domains of a holistic assessment and there is a lack of coordination between health and social care to support sharing of patient information
required. This results in patients having repeated assessments at a point in the
pathway, providing the same information to different professionals.
The White Paper, Our Health, Our Care, Our Say (4) included a commitment to
develop a common assessment framework for all adults. The work around a
Common Assessment Framework aims to deliver a more person-centred and
integrated approach to assessing people’s need for support from health and social
care services and the support needs of their carers. The specific aims of a common
assessment framework are to:
• Improve outcomes for adults by ensuring a person centred and holistic
assessment of need, focused on delivering individual outcomes;
• Support improved joint working between health and social services;
• Increase efficiency through better information sharing.
Developments are on-going with regard to the Common Assessment Framework
through the testing process and eventual development of an electronic care plan and
tool. Connecting for Health are undertaking further work to define the content of the
NHS Care Record and cancer assessment specification needs to become a standard
template in the electronic messaging systems. The Holistic Patient Assessment Essay.
In West London, the Holistic Assessment Cancer Network Working Group was set up
and carried out a review of the tools for implementation of the Holistic Patient
Assessment. The group then developed an aide memoire that would be adaptable
and relevant to all assessments currently in use (Appendix 1). The Aide Memoire
was adapted from the Gold Standards Framework PEPSI COLA aide memoire.
The aide memoire is a tool to support practitioners carrying out assessments and can
be used with assessment tools currently in use. It promotes communication and
support and provides a framework to consider patients’ holistic needs.
The aide memoire encompasses all the domains of a holistic assessment through the
acronym PEPSI COLA:
P – Physical
E – Emotional
P – Personal
S – Social support
I - information and communication
C – Control and autonomy
O – Out of Hours
L- Living with your illness
A – Aftercare
In each domain the tool identifies:
• Potential anticipated patient issues and concerns
• Cue questions to ask patients and carers
• And resources for professionals to signpost to.
Key principles of carrying out a holistic assessment are that:
• The assessment should be patient ‘concerns-led’
• Helping patients to assess their own needs should be central to the process
• Patient consent is necessary to the assessment process
• Professionals undertaking assessment should have reached an agreed level
of competency in key aspects of assessment
• Patient preferences for communicating with particular professionals, their
family and friends, should be taken into account
Documenting the assessment should be in accordance with the current assessment
tool being used, e.g: FACE.
The Holistic Assessment should be undertaken by staff at the key stages of the
patient pathway as indicated above. The documented assessment should be
transferred to the relevant health care professionals involved in the patient’s care.
The role of the Key Worker is vital in the process of making the assessment and
ensuring this is shared within the multidisciplinary team. Patient held records will
facilitate this process.
Understanding the Assessment Process
1. Assessment:
It is the dynamic and continuous process of collecting, verifying, and organizing
information about a person within a particular context. The process starts with the
first nurse-patient encounter and continues throughout the nurse-patient relationship.
Emphasis is on health status, environment, strengths and limitations as well as on the
person’s cultural beliefs and practices. Assessment yields an individualized patient
database from which the nurse identifies the status of actual or potential limitations
and strengths; collaborates and contributes to the plan of care and reviews and
interprets the plan of care; makes decisions regarding the selection and
implementation of appropriate nursing interventions based on the plan of care;
intervenes; evaluates by monitoring and recognizing changes in patient status in
response to interventions; reports and records with a view to assist the patient to
achieve or to maintain optimal health. Assessment is a deliberate and/or incidental
activity.
An example of the process described would occur when the LPN determines a
patient’s blood pressure is low prior to the next scheduled dose of antihypertensive
medication. The licensed practical nurse knows that administering an
antihypertensive at this time may compromise the patient and decides to withhold the
medication. The nurse documents the findings and informs and consults with the
registered nurse or other appropriate healthcare provider.
2. Sources of data:
a. Background nursing knowledge obtained from multiple and varied sources.
Knowledge helps the nurse
i. determine the information to seek in a given situation
ii. differentiate relevant and irrelevant data
iii. prioritize data
iv. recognize data needing to be verified and/or clarified
v. facilitate systematic organization of data
vi. analyze data based on a set of norms
b. Clinical record: medical history, current medical problems and interventions,
laboratory values and results of other diagnostic tests, previous assessments,
and information from other healthcare providers. The Holistic Patient Assessment Essay Paper.
c. General observation of the patient, environment and interpersonal interactions.
d. A health history/interview accompanies the physical assessment. Typically
health history includes biographic data, current health problems, past health
history, family history of health challenges, current medication and
treatments, allergies, personal social history (role and relationship patterns),
cultural beliefs and practices related to health (health promotion with attention
to exercise, diet; protection patterns such as avoiding unintentional injuries;
and prevention evident with immunization compliance), review of systems
and in particular noting activities of daily living and advanced directives.
The information from the interview facilitates
i. a focus for the assessment and helps identify patient expectations and
concerns, and offers the patient’s perspective and meaning of the data
ii. identification of strengths and limitations to guide the planning of
nursing care.
e. Physical assessment includes 4 basic techniques: inspection (look), palpation
(touch), percussion (tap) and auscultation (listen) (IPPA). To enhance
proficiency of assessment use the order of IPPA except when carrying out an
abdominal assessment
i. the patient may be asked to demonstrate certain activities such as
walking, bending, detection of noises, speaking, smells and reading a
visual acuity chart
f. Assessment further includes the use of diagnostic tests such as laboratory
tests, pathology reports, radiographs, electrocardiograms, etc.
g. Consultations: family and friends provide data about the patient’s usual
behavior patterns and coping mechanisms, recent changes in health status
including cognitive and psychosocial changes, available resources, support
system, and additional concerns the patient may not have expressed. Other
sources include paraprofessionals who may have interacted with the patient.
3. Domains to be assessed: The Holistic Patient Assessment Essay.
The domains are interdependent and contribute to the development of a holistic
picture. The domains include
a. Physiologic: biological, physical, and functional characteristics.
b. Psychologic: emotional and cognitive features.
c. Social: dynamics of interpersonal relationships with individuals and groups.
18
d. Cultural: primary language, shared beliefs, perceptions and practices based on
common heritage or ethnic and/or racial background.
e. Spiritual: beliefs and values that provide strength, hope and meaning to life;
religious tenets and practices.
f. Developmental: evolutionary process over time from maturation, experience
or learning.
4. Types of data:
Data is classified as subjective and objective.
a. Subjective: what the person tells the assessor (i.e. description of pain,
perceptions, feelings or experiences).
b. Objective: evident, measurable, and verifiable observations such as vital
signs, odours, redness of a wound, hostile behaviour, and laboratory and
medical imaging findings.
c. Correlation of subjective and objective data: e.g. is shortness of breath
supported by decreased breath sounds on auscultation or dullness to
percussion?
5. Purpose of assessment:
The purpose is to plan care by identifying health care needs. Such identification may
include
a. Health promotion needs: enhance well being, preventative interventions.
b. Health risk factors
- Nonmodifiable risk factors i.e. biological, congenital, hereditary.
- Modifiable risk factors i.e. diet, smoking, and sedentary lifestyle.
c. Potential/risk health problems e.g. person with traumatic wound is at risk for
infection.
d. Actual health problems to direct action aimed at regaining or facilitating
optimal health.
6. Types of assessments:
For the purpose of this resource, assessments are classified as:
comprehensive/full,
quick priority, and
focused
a. Comprehensive assessment occurs when an individual is admitted to a health
care/residential setting and at individually determined intervals during a
continuing patient-health care provider relationship (i.e. anytime a baseline or
re-assessment is indicated). Specific responsibilities are outlined in the
practice expectations document. The Holistic Patient Assessment Essay Paper.
b. Quick priority assessment is one that is carried out efficiently when a rapid
assessment is in order to familiarize oneself with the assigned patient such as
at shift change, with a change of patient assignment or temporarily assuming
care of a patient, and or a validation of patient status. A mnemonic ABC I/O
PS is a useful trigger to recall the technique.
A: AIRWAY:
Ensure airway is patent and protected, for example, not compromised by
position, supports, etc.
Can the patient speak?
B: BREATHING:
Determine the ease/effort and rate.
C: CIRCULATION:
Assess tissue perfusion by checking pulses, skin temperature and
color of the extremities.
Is edema present?
Determine the level of consciousness and orientation.
I: IN:
What is going in? Verify the identity of every substance entering the
patient and the operation/function of the device used for substance
delivery. Such checks include power source, electronic settings
controlling flow rates and pressure settings.
What is the condition of tissue surrounding the ports of substance
entry? The Holistic Patient Assessment Essay.
Ensure tubing/delivery devices are free of twists, kinks, obstructions, and
tension. Follow the source of substance delivery to its point of entry.
O: OUT:
What is coming out? What is the character and amount of drainage from
wounds, tubes, and body orifices?
Check dressings, drainage tubes, and devices, condition of ports of exit.
Do they need reinforcement, repositioning, emptying?
P: PAIN and overall comfort level:
Have the patient identify and describe pain using a pain scale.
What factors relieve/aggravate the pain?
Consider pain in the context of last analgesic/intervention.
Verify patient comfort such as related to position, temperature, anxiety,
and stress.
S: SAFETY:
Assess the environment. Are suction and oxygen delivery systems
functional and ready for use? Is the bed in a low position? Are
bed/wheelchair brakes engaged? Are restraints used according to
protocol and policy? Is the call bell accessible? Are personal items
within reach?
20
Conclude the quick priority assessment with a focused assessment related to the
patient’s health challenge. For example, for a patient with total hip replacement,
complete the following: check position of abductor pillows, are dressings intact,
determine character and amount of drainage on dressing/bedding, is drainage
device functioning and amount and character of drainage in the receptacle,
neurovascular check, pain level assessment, nausea, etc.
c. Focused assessment addresses a particular problem or issue and may be done
in response to
i. changing health status that precludes a full assessment e.g. acute pain
or respiratory distress
ii. presentation of an episodic problem such as a sore throat
iii. the need to determine progress of a specific potential or actual health
problem
iv. the need to determine the effectiveness of an intervention e.g. relief of
pain by position change and/or medication
v. the assumption of care by a new care provider e.g. at the beginning of
a shift
Quick priority and/or focused assessments are used more often than a
comprehensive assessment. The findings of the more abbreviated assessment(s)
may determine the need for a comprehensive assessment.
7. Process of data collection:
Data is systematically gathered and organized. The process is guided by a structure
based on a variety of approaches. Some recognized approaches include
a. Physiologic: body systems approach that is sometimes referred to as a
medical model or a head-to-toe assessment.
b. Functional health patterns: identification of behavioural health patterns over
time which facilitates recognition of functional and dysfunctional patterns.
c. Needs models based on Maslow’s hierarchy of needs. For a review of
Maslow’s hierarchy click on the link below.
- http://web.utk.edu/~gwynne/maslow.HTM
d. Prescribed agency driven formats which are generally an adaptation or hybrid
of various models.
8. Context of data collection:
Ensure that you consider individual variations that may impact data collection and
subsequently influence interpretation of that data. Such variations include
growth and development
concurrent health challenges
culture and race
medications
9. What to do with the data:
The assessor should record data throughout the assessment followed by formal
documentation in an organized framework using correct terminology. Organizing data
may reveal a fit of data in more than one body system. Select the most appropriate
system/category and place it there. For example, getting up to the bathroom four
times a night may be relevant to renal system (urinary pattern) or musculoskeletal
system (sleep-rest activity pattern). Ensure that documentation clearly identifies
objective and subjective data. The process continues with
a. Comparative analysis of data
i. compare data with standards and norms. A standard or norm is a
generally accepted value, model or pattern. Examples include normal
lab data, growth and developmental stages, normal vital sign
parameters, cultural norms for behaviour, and usual symptom patterns
for a specific health problem
ii. identify which data match the norm and which vary
iii. compare data to what is normal for the patient
iv. begin to determine which data are relevant and which are irrelevant
b. Making and validating inferences
· Inferences are the process of assigning meaning to data.
· As soon as possible, inferences need to be validated with the person e.g.
are you feeling anxious? The Holistic Patient Assessment Essay.
c. Developing clusters of related data.
· The goal is to identify patterns.
· The inductive approach (reasoning from specific observations to general
statements) within a category and from different categories to form
patterns.
· The ability to recognize patterns is directly related to the nurse’s theoretical
knowledge base, clinical experience and general life experience.
· Identify and obtain missing data that may become known while trying to
identify patterns.
· Identify inconsistent data as they relate to patterns formulated.
· Determine a list of health care strengths and limitations.
Based on the cluster of data, formulate a list of identified actual and potential problems
with associated etiology. For example, impaired skin integrity related to immobility.
Identification of the problem forms the basis for planning individualized patient care
aimed at maintaining/optimizing health.
LPN Approach to Patient Assessment
Adequate preparation is essential to enhance patient and nurse comfort facilitating
execution of a thorough and competent assessment. The assessment includes the
interview; therefore the nurse must use effective communication strategies throughout the
procedure. An assessment may elicit a variety of patient responses. These could include
fear, anxiety, and/or discomfort. Some patients may consider the process an invasion of
their privacy. Thus the nurse’s competency impacts the process and outcome.
Proficiency and expertise are gained with a systematic approach and practice.
Preparation:
- Ensure a well-lit environment that is conducive to carrying out a safe and
competent assessment that includes the health history/interview.
- Allow sufficient time to carry out the assessment.
- Organize self with necessary equipment, as appropriate
Watch with a second hand Marking pencil
Thermometer Scale
Stethoscope Tongue depressor
Sphygmomanometer Safety pin – sharp/dull assessment
Pulse oximeter Cotton ball – fine/light touch
Penlight/flashlight
Measuring tape
Specialized equipment based on
context of practice
Pocket ruler
- Attend to patient’s basic needs for safety, comfort such as pain management,
elimination needs, warmth, etc.; privacy and dignity. Maintain patient
comfort throughout the assessment.
- Introduce self, explain the process, and make general observations about
appearance, body features, state of consciousness and arousal, speech, body
movements, obvious physical signs, nutritional status, and behavior.
- Determine patient’s ability to communicate since a family member,
interpreter or aids may be necessary to competently carry out the assessment.
- Assess whether variables such as the effect of a recently administered
medication may interfere with the accuracy and validity of the assessment.
- Be sensitive, unhurried and reassuring. Verify patient’s comfort with
proceeding e.g. a brief rest period may be necessary.
- Avoid negative and judgmental reactions in response to unexpected findings.
The use of empathy and acceptance are vital to forming a therapeutic nursepatient relationship that starts with the initial interaction. The Holistic Patient Assessment Essay.
- Wash hands prior to commencing the assessment.
- Always use the same systematic approach to facilitate a comprehensive
assessment with minimal repositioning of the patient.
- PQRSTA is an acronym describing one framework that is useful in gathering
data about any complaint/problem/symptom the patient may reveal or that the
nurse observes. Examples of such concerns include pain, shortness of breath,
fatigue, etc.
PQRSTA represents the following
3 Provocative or Palliative – What causes the symptom? What
makes is better or worse? What have you done to get relief?
3 Quality or Quantity – What is the character of the symptom i.e.
pain: is it crushing, piercing, dull, sharp? How much of it are you
experiencing now?
3 Region or Radiation – Where is the symptom? Does it spread?
3 Severity – How does the symptom rate on a severity scale of 1 to
10 with 10 being the most intense?
3 Timing – When did the symptom begin? How long does it last?
How often does it occur? Is it sudden or gradual?
3 Associated signs and symptoms of the chief complaint – Does the
primary problem result in any other clinical manifestations, e.g. the
pain accompanied by diaphoresis, nausea, vomiting?
OVERVIEW OF A PATIENT ASSESSMENT
As identified, a comprehensive assessment includes multiple components. This includes
gathering information from a health history, carrying out a general survey, measuring
vital signs, and assessing the body systems and psychosocial domain. The quality and
thoroughness of the assessment is strongly linked to the nurse’s competency in
assessment and knowledge of the patient’s present and past health challenges. Knowledge
of normal body function (physiological and psychological) is fundamental to carrying out
a comprehensive assessment. Therefore a body system overview is presented prior to the
corresponding detailed assessments for each of the domains. As indicated previously, the
practitioner’s comfort level assessing the systems will vary based on context of practice,
range of competencies, frequency of completing assessments, and type of assessments
regularly completed.
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GENERAL SURVEY
This is the first impression of the patient that provides vital information about the
patient’s behaviour and health status. First observation must include airway, breathing
and circulation (ABC) assessment. Further initial impressions are made at this time that
include apparent age, gender, ethnicity, race, height, weight, nutritional status,
development, body type, posture, movements, aids, prosthetics, speech, dress, grooming,
personal hygiene, and signs of distress, facial characteristics, presence of family or
significant other(s) and psychological state.
Ask about the patient’s perception of their health.
Description of their health (usual, current), preventative measures,
previous hospitalizations & expectations of current experience,
description of illness (onset, cause), prior treatment (including
compliance, anticipated self-care problems).
Proceed with an organized systematic data collection to ensure all the elements of
assessment that follow are explored with the patient and/or family/friends, as appropriate.
Over time a nurse develops her/his own systematic approach to assessment. Consistency
in a systematic approach can be gained with the use of a head-to-toe framework and
IPPA. IPPA is the conventional approach with the exception of the abdominal
assessment. Make certain confidentiality is always maintained and that you have the
patient’s permission to gather data from a designate.
Note that in several sections, repetition and overlap of data collection occurs.
This ensures particular elements are considered in the event a focused
assessment precludes a comprehensive assessment. A detailed assessment
does not follow the endocrine system since this system is highly integrated with
other body systems. Relevant data is gathered while carrying out other
interdependent systems.
VITAL SIGNS
· Temperature
· Pulse (rate, rhythm, strength-quality)
· Respirations (rate, rhythm, depth)
· Blood pressure – supine, sitting, standing, right and left arms
· Pulse oximeter
The Holistic Patient Assessment Essay.
People with cancer require supportive and palliative care at different stages of the
patient pathway from a range of service providers in the community, hospitals,
hospices, care homes and community hospitals.
Supportive Care is defined by the National Council for Palliative Care: The Holistic Patient Assessment Essay.
‘…Supportive Care helps the patient and their family to cope with cancer and
treatment of it – from pre-diagnosis, through the process of diagnosis and treatment,
to cure, continuing illness or death and into bereavement. It helps the patient to
maximise the benefits of treatment and to live as well as possible with the effects of
the disease. It is given equal priority alongside diagnosis and treatment.’1
NICE Improving Outcome Guidance for Supportive and Palliative Care for Adults with
Cancer (2004) identified that there are a series of points on the patient pathway
where a patient may have particular or greater supportive care needs and
recommends that at these key points the patient should be offered a holistic
assessment (2). These points occur generally when there is a significant change in
diagnosis, treatment, condition, prognosis or the carer’s ability to cope. (3)
Key points are:
1. At or around the time of diagnosis (this may include circumstances in which
supportive care needs are manifest before diagnosis and particularly where
the process of investigation is protracted)
2. Commencement of treatment
3. Completion of the primary treatment plan
4. At each new episode of disease recurrence
5. At any other time that the patient may request
6. At any other time that the professional carer may judge necessary
7. The point of recognition of incurability (in some cases this may precede death
by years)
8. The beginning of end of life (in most cases this precedes death by less than
one year)
9. The point at which dying is diagnosed
Points 7 to 9 can be more difficult to determine and are heavily reliant on professional
judgement in recognising these points.
In respect of ‘end of life’ the Gold Standards Framework Team has developed a set
of prognostic indicators that may help professionals decide when it begins.
Three triggers are suggested:
• The Surprise Question – Would you be surprised if this patient were to die in
the next 6-12 months?
• Patient Choice – The patient with advanced disease makes a choice for
comfort care only (not curative treatment)
• Patient Need – The patient is in special need of supportive or palliative care
• Clinical Indicators – General predictors of end stage illness (5)
The Liverpool Care of the Dying Pathway documentation provides guidance
information for healthcare professionals about recognising dying and the key
indicators to identify when to place a dying patient on the pathway.(6)
Cancer patients may not be offered or have access to a holistic assessment at the
key points of need outlined and this affect whether they receive appropriate and
timely care.. There are broadly four distinct barriers to the provision of services for
patients and carers.
1. Needs may not be met because they are not recognised either by healthcare
professionals or by patients themselves
2. The relevant services may not be available because they had not been
planned or funded
3. The relevant services may exist but not be accessed because key
professionals are unaware of them
4. The relevant services may fail to bring maximum benefit because of poor
communication and coordination.
There are a number of assessment tools currently being used by various health and
social care professionals (eg: FACE and single assessment) but as yet these tools
do not cover all the domains of a holistic assessment and there is a lack of coordination between health and social care to support sharing of patient information
required. This results in patients having repeated assessments at a point in the
pathway, providing the same information to different professionals.
The White Paper, Our Health, Our Care, Our Say (4) included a commitment to
develop a common assessment framework for all adults. The work around a
Common Assessment Framework aims to deliver a more person-centred and
integrated approach to assessing people’s need for support from health and social
care services and the support needs of their carers. The specific aims of a common
assessment framework are to:
• Improve outcomes for adults by ensuring a person centred and holistic
assessment of need, focused on delivering individual outcomes;
• Support improved joint working between health and social services;
• Increase efficiency through better information sharing.
Developments are on-going with regard to the Common Assessment Framework
through the testing process and eventual development of an electronic care plan and
tool. Connecting for Health are undertaking further work to define the content of the
NHS Care Record and cancer assessment specification needs to become a standard
template in the electronic messaging systems. The Holistic Patient Assessment Essay.
In West London, the Holistic Assessment Cancer Network Working Group was set up
and carried out a review of the tools for implementation of the Holistic Patient
Assessment. The group then developed an aide memoire that would be adaptable
and relevant to all assessments currently in use (Appendix 1). The Aide Memoire
was adapted from the Gold Standards Framework PEPSI COLA aide memoire.
The aide memoire is a tool to support practitioners carrying out assessments and can
be used with assessment tools currently in use. It promotes communication and
support and provides a framework to consider patients’ holistic needs.
The aide memoire encompasses all the domains of a holistic assessment through the
acronym PEPSI COLA:
P – Physical
E – Emotional
P – Personal
S – Social support
I - information and communication
C – Control and autonomy
O – Out of Hours
L- Living with your illness
A – Aftercare
In each domain the tool identifies:
• Potential anticipated patient issues and concerns
• Cue questions to ask patients and carers
• And resources for professionals to signpost to.
Key principles of carrying out a holistic assessment are that:
• The assessment should be patient ‘concerns-led’
• Helping patients to assess their own needs should be central to the process
• Patient consent is necessary to the assessment process
• Professionals undertaking assessment should have reached an agreed level
of competency in key aspects of assessment
• Patient preferences for communicating with particular professionals, their
family and friends, should be taken into account
Documenting the assessment should be in accordance with the current assessment
tool being used, e.g: FACE.
The Holistic Assessment should be undertaken by staff at the key stages of the
patient pathway as indicated above. The documented assessment should be
transferred to the relevant health care professionals involved in the patient’s care.
The role of the Key Worker is vital in the process of making the assessment and
ensuring this is shared within the multidisciplinary team. Patient held records will
facilitate this process.