It is important to understand that assessment is important for all activities that he could do. It does not happen just once, but is a continuous process at regular intervals, depending on the patient's condition. The most common time for a thorough evaluation, the patient has acute or continue treatment, but there may be other times when it is determined to be necessary.
When assessing a patient includes both formal and informal assessment. A formal evaluation of a collection of objective information on the patient's condition by asking him questions and get answers. An informal evaluation will cover the things you see a patient, when you talk to them and may have physical symptoms and subjective information, such as their mood and behavior. Structure of these estimates, discussed in more detail in this chapter. Estimate of the physical symptoms of life will also be taken. To ensure effective assessment, patient care is necessary and provides a baseline from which progress can be measured. In order for an effective treatment plan and delivered a structured approach called the nursing process is used.
"Nursing process" is being planned, problem-solving approach to meet the patient's health and medical needs (Lippincott 2000). This is a systematic series of events, where the first step is to assess the needs of the patient gathering of objective and subjective information. The next step is the interpretation of this data when the actual or potential problems that the patient has taken place. It could be called the nursing diagnosis (Lippincott 2000). Nursing is designed to correct or prevent these problems, and problems can then be given priority, so that he is patient care needs are met. These objectives are used to plan the direction and type of nursing intervention is necessary.
They should be patient, focused, and SMART:
Measurable
Be achieved
Realistic
Time Bound
For example, a patient may indicate his or her concerns to the extreme shortness of breath at rest. Short-term goal may be to his respiratory rate is 25-28 breaths per minute for four hours. This would give time to the medical and nursing care measures to take effect. For this purpose, the SMART study meets the special care that helps to achieve the objective. There are examples of problems and objectives for the whole book, and medical intervention to achieve the goals.
If the results of the implementation of nursing care should be assessed. The assessment provides an opportunity to see how the patient reacts in nursing, and the extent to which objectives have been achieved (Lippincott 2000). As a result, the evaluation may be necessary to change the targets, as has previously been the problem no longer exists, and it can appear in a new one. If targets are not met then the case should be re-examined and re-objectives of the intervention.
The whole series of the nursing process, which is:
Assessment - the collection of objective and subjective information
nursing diagnosis - potential or actual health problems
Planning - plan for maintenance work to address identified problems, or termination of appointment - the delivery of nursing
Evaluation - Evaluation of the effectiveness of nursing care and the success rate of solving the problem.
Although the nursing process provides the framework needed for nursing care model provides a structure in which the treatment is given. He takes the role of nurse, patient care needs and objectives, if it is delivered. Nursing model is established beliefs and values, people, society, environment, health and nursing, criteria, and it covers the social, physical and mental health determinants, all of these sites (Pearson et al. 1996).
Preferably choose a model to the needs of each patient's care (Roper et al. 1998). For example, a patient needs for rehabilitation after an accident benefit model, which encourages a progressive return to independence, rather than depending on the health-care professionals. Another patient in the terminal phase of illness may become increasingly dependent on the health-care professionals to meet their physical therapy should focus on providing comfort and relief of symptoms, and make the most of the remaining time. In general, nursing his clinic model is selected, it is proposed to increase the supply of nursing is clearly the nature and purpose of the service and provide the structure for recording and documenting the findings and activities to promote continuity of care (Iyer and Camp 1999).
If you follow a good assessment is often difficult to see how they got all their information, because they difficult process seem easy. It may look more like an informal discussion of the patient and his sister-structured assessment process. But the experience of interacting with patients' ability to identify important information and guidelines for discussion and information-gathering tools. The patient is first seen in the treatment of certain evaluation activities that take place, and when they ripen, they will gather the required information. These steps are: first impressions, assessment interview, focused on the evaluation and physical assessment.