Chapter 2: Admissions and assessment
Skip chapter table of contents and go to main content
Source: Reproduced from Weber and Kelley ([88]) with permission of Lippincott Williams & Wilkins.
Inpatient assessment and the process of care
To appropriately care for a patient within the hospital setting or the community, the nurse must assess the patient in order to develop a care plan tailored to the individual (Saxon and Lillyman [75]). The nursing process is an organized, systematic and deliberate approach that aims to improve standards in nursing care (Rush et al. [73]). This process is cyclical, ongoing and generally used in conjunction with various theoretical nursing models or philosophies. The process is both holistic and problem solving; each stage is intimately interconnected with the other stages and is explicable only by reference to the whole – used in partnership with the patient and their family. This process, similar to those used in problem solving and scientific reasoning, incorporates assessment, diagnosis, planning, implementation and evaluation phases, as demonstrated in Figure 2.1 and Table 2.1 (Pratt and Van Wijgerden [65]). Each step of the nursing process depends on the accuracy of the preceding step. This nursing process has evolved over the past decades and is now used by nurses throughout the world as a framework for providing individualized, person‐centred care.
Figure 2.1 Phases of the nursing process. Source: Reproduced from Weber and Kelley ([88]) with permission of Lippincott Williams & Wilkins.
Table 2.1 Phases of the nursing process
| Phase | Title | Description |
|---|---|---|
| 1 | Assessment | Collecting objective and subjective data |
| 2 | Diagnosis | Analysing subjective and objective data to make a professional nursing judgement |
| 3 | Planning | Determining outcome criteria and developing a plan |
| 4 | Implementation | Carrying out the plan |
| 5 | Evaluation | Assessing whether the outcome criteria have been met and revising the plan as necessary |
