For a person’s needs to be addressed, they need to be identified. Guided by the key elements of nursing care planning, a comprehensive assessment includes:
Assessment measures needs across these domains using a systematic approach including use of validated tools and input from the care team. Ongoing reassessment is key to monitoring for changes in a person's condition and needs as the illness progresses.
As with the principles of person-centred care, assessment needs to be tailored and individualised to the person. It will also depend on the stage of illness. Assessment as part of prognosis and ongoing care includes some common approaches but also others that are specific to disease stage and the changing needs of the person and their family including distress. Identifying that a person is imminently dying also requires skill in assessment and this is considered in the section on The Dying Patient.
Assessment is fundamental to nursing care. Early identification and correct assessment of physical, psychosocial, or spiritual symptoms guide care to prevent and relieve suffering of people living with a life-limiting illness and as they approach death. Regular comprehensive and holistic assessments help detect changes over time and monitor response to treatment. This ultimately informs the person’s care plan.
Combining a systematic approach to assessment with asking people how they are, if they are experiencing any difficulties/symptoms and how this is affecting them is the best way to achieve a comprehensive assessment.
For more information on assessment in practice see assessment in ongoing care.
The sections on assessing distress and the needs of assessing carers and family can help with these aspects of holistic care.
Good communication skills can positively affect assessment and care planning.
Page created 26 September 2022