Assessment and Care Planning for the Adult in Hospital. This essay will include a case study of a patient I have nursed in practice.

Authors Avatar by vhb1977 (student)

Assessment and Care Planning for the Adult in Hospital

Client Care Analysis


According to the NHS Information Centre, Hospital Episode Statistics for England, (HES 2011) during the period of August 2010 to July 2011, over 14.8 million people were admitted to hospital and 5.3 million of these were emergency admissions.  These statistics represent individual people who have their own needs, but share the common need for their healthcare professional to provide expert care to them during their time in hospital.  Effective care planning and accurate, ongoing assessments of our patients and their needs is essential in achieving a positive experience for the patient and their continued recovery.

This essay will include a case study of a patient I have nursed in practice.  I will make a holistic assessment of my patient’s needs.  I will identify two of these needs and discuss these with regard to the care given, also discussing psychosocial, biological and patho-physiology of these issues.  I will reflect on my own skills with regard to the care planning and delivery process and refer to relevant literature and the evidence base concerning assessment, care planning and delivery of appropriate care.

Main body

Castledine (2004) tells us that all nurses should carry out a patient assessment automatically as this is the first stage in ascertaining the health of the patient.  A past medical history should be obtained and a physical assessment made as the information gained will enable the nurse to provide evidence based care tailored to the patient’s individual needs, both immediate and long-term.  

The initial assessment interview with the patient not only allows the nurse to gather  the required baseline information about the patient, but can also serve as the starting point for the establishment of a therapeutic relationship between the service user and their nurse ().

Assessment of a patient involves gathering as much information (data) as possible about the person and then using that information to form a plan of action with regard to the level of care, support and intervention that  the patient will require (Hamilton & Price, 2007).  

Van Dyke Hayes & Sparks Ralph (2009) point out that nurses use several ways of collecting information about their patient, such as observational skills, interviewing and conduction of physical examinations.  An experienced nurse can usually assess a patient using these methods simultaneously.  

A thorough patient assessment should include the collection of a past medical history (collection of subjective data).  Collection of objective data via physical examination is also a vital part of patient assessment.  Measurements of the patient’s weight, height, respiration, temperature and blood pressure are recorded.  The extent of the physical examination the nurse will conduct is dependant on their experience and also the client’s needs (Wilson & Giddons, 2009).

Hamilton & Price (2007) remind us that the precise recording of our assessments is an important way to communicate a patient’s progress to other members of the heathcare team.  Wilson & Giddons (2009) agree and stress that accurate documentation of a patient assessment is vital as other healthcare providers will also be using this information and if the data is incomplete or flawed then this will have a negative impact on the effectiveness of the whole healthcare team.  

To ensure that patient care is organised in a simple and systematic way, a 4 stage nursing process is used.  The 4 stages are: assessment, planning, implementation and evaluation.  Once the cycle of all 4 stages has been completed, if necessary the nurse can start the process again with a re-assessment of the patient’s needs (Brooker & Nicol, 2003).  The process of nursing care is supported by various models, one of which is the Roper, Logan & Tierney (2000) model, which is the main model used in nursing today.

The patient upon whom my care study is based is a 45 year old man who has been admitted to the ward for a right total hip replacement.  To ensure compliance with the NMC Code 2008 and the regulations concerning patient confidentiality, the patient will be referred to as Chris.  

Chris is divorced and lives with his new partner and her two teenage sons.  His own son from his first marriage is 8 years old and lives with his mother but visits Chris at weekends and school holidays.  Chris is a self employed mechanic, he had a motorbike accident at 23 years old which has since resulted in his right hip becoming severely arthritic.  Over the last 18 months Chris’s pain has become unbearable, his mobility and quality of life has decreased to such an extent that he has been advised that a total hip replacement (THR) is the best solution to the problem.  Chris has also been advised that due to his age and lifestyle, he may well require further surgery later in life to revise the procedure as currently hip replacements only last about 20 years (NHS, 2010).  Chris’s main concern at the moment is that he is unable to work until he has recovered from the procedure and as he is self employed he is losing money.  

Join now!

The first aspect of care I will explore with regard to nursing Chris is effective pain management.  In 2010 The Australian and New Zealand College of Anaesthetists (ANZCA) described pain management as a “fundamental human right”.  ANZCA furthered this statement by saying that pain management is fundamental to the ethical and client centred practice of modern medicine.

In 2007 the Chronic Pain Policy Coalition referred to pain as being the 5th vital sign.  This is to remind nurses that if pain were monitored routinely and regularly alongside other vital signs such as blood pressure, temperature and respiration, they could ...

This is a preview of the whole essay