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This chapter gives an overview of inpatient assessment, the process of care and the importance of observation in the assessment process.
Assessment forms an integral part of patient care and is considered to be the first step in the process of individualized nursing care. It provides information that is critical to the development of a plan of action that enhances personal health status. Early and continued assessments are vital to the success and management of patient care. It is critical that nurses have the ability to assess patients and document their findings in a systematic way.
Advanced nursing practice provides a high quality of care (McLoughlin et al. ) and has emerged in response to changing healthcare demands and the need for a flexible approach to care delivery. Key roles within advanced nursing practice include conducting comprehensive health assessments, demonstrating expert skills in diagnosing and treating acute and chronic illness, and making specialist referrals as required. Physical assessment is a core procedure for those undertaking this role and so is incorporated into this chapter.
The patient's age, health and mode of presentation will determine the extent of the physical assessment required (Innes et al. ). Observation – coupled with one or more of cardiovascular, respiratory or abdominal examinations – is discussed in this chapter. See Chapter c14: Observations for information on neurological assessment.