Assessment

Identifying and monitoring care needs

What it is

For a person’s needs to be addressed, they need to be identified. Guided by the key elements of nursing care planning, a comprehensive assessment includes:

• physical symptoms
• psychological/psychiatric and cognitive symptoms
• illness understanding and care preferences
• social and economic needs
• existential, religious, and spiritual issues
• care coordination and continuity.

Assessment measures needs across these domains using a systematic approach including use of validated tools and input from the care team. Ongoing reassessment is key to monitoring for changes in a person's condition and needs as the illness progresses.

As with the principles of person-centred care, assessment needs to be tailored and individualised to the person. It will also depend on the stage of illness. Assessment as part of prognosis and ongoing care includes some common  approaches but also others that are specific to disease stage and the changing needs of the person and their family including distress. Identifying that a person is imminently dying also requires skill in assessment and this is considered in the section on The Dying Patient.

Why it matters

Assessment is fundamental to nursing care. Early identification and correct assessment of physical, psychosocial, or spiritual symptoms guide care to prevent and relieve suffering of people living with a life-limiting illness and as they approach death. Regular comprehensive and holistic assessments help detect changes over time and monitor response to treatment. This ultimately informs the person’s care plan.