This essay will emphasise the importance of assessing the needs of a patient within
the nursing care along with the use of the twelve activities of daily living. It will focus
of the needs assessment for a patient called Carl and discuss the Malnutrition
Universal Screening Tool (MUST).
Nursing assessment is the first stage of the nursing process between the patient and
the nurse upon admission to determine the type of care, treatment and service for
the individual. Important data regarding the patient's health is collected and enables
the nurse to develop a care plan with regards to the level of support, care and
intervention that is needed for the patient (Hamilton and Price, 2007). The
assessment interview also enables the nurse to gather the necessary data. It
provides information as the starting point for the establishment of a therapeutic
relationship built between the nurse and the patient (Crumbie, 2006). The
assessment will identify the type of treatment and service needed through mental,
physical and environmental procedures, it is vital to consider the cultural and spiritual
needs of the patient (Smith and Field, 2011). Castledine (2004) informs us that all
health care professionals should carry out an assessment routinely as it is the most
important stage in knowing the health of a patient.
The nurses should double check and clarify the information collected to ensure that it
is accurate and complete (Altman, 2010). Confirming the data with the patient helps
to avoid any misinterpretation, if the assessment is incorrect or incomplete, the
nursing diagnoses are also likely to be incorrect (Matthews, 2010). The assessment
should be written in accordance with the Nursing and Midwifery Council guidelines
for record keeping, the information collected should be factual, accurate, consistent
and written clearly (NMC, 2008). Hamilton and Price (2007) state, the accurate
recording of the needs assessment is an important way to communicate to other
members of the health care team about the progression of the patient.
As previously mentioned, this assignment is based on a 68 year old patient called
Carl. Carl is a retired bus driver who lives with his wife. He smokes 20 cigarettes a
day and is a non-drinker. Carl's wife is finding it difficult to manage his behaviour as
he seems to be suffering from increased forgetfulness. He is frustrated and irritated
as he is unable to read to his grandchildren due to no picture recognition. Carl is
currently taking statin, betablockers, aspirin, and frusemide. To ensure that the
patients care is planned in a systemic way the five stage nursing process is used.
The five stages are assessment, nursing diagnosis, planning, implementation and
evaluation. Following these stages in this order allows the nurse to organise and
prioritise patient care and helps to ensure that none of the important information is...