Assessment and care planning are core responsibilities of registered nurses.
Registered nurses may use tools to collect the data for their assessments. For many assessments they must rely on data collected by other members of the team.
This is particularly so for pain and behaviour where the frequency and incident data may be collected by many people.
Assessment tools should be:
- validated for use with the elderly
- culturally relevant for the population they are used with, and
- all persons administering the tools should be adequately trained in their use.
The data collected must be analysed in the context of what is known about the resident:
- diagnoses impacting on care
- what the resident says about the issue
- how they have managed the symptom in the past
- their general approach to problems, and expressed wishes regarding care
- what family and caregivers who know the resident well have observed
- current goals of care; curative or palliative approach and comfort care.
It is only then that a holistic and comprehensive assessment can be made and a care plan developed.
Tools are not only used to identify need. Repeated use of the same tool will give evidence for evaluating the care given. The appropriate use of tools has been shown to improve resident outcomes.
Tools do not replace clinical judgement or clinical knowledge. The appropriate use of assessment tools combined with evidence-based clinical care promotes good outcomes for residents.