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Nursing - Person - Centred Assessment and Care Planning Sample

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Nursing - Person - Centred Assessment and Care Planning Sample


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Question 1

This assessment is conducted to examine the level of cognitive functions in an individual. There can be many reasons for this assessment and can only be performed by healthcare professionals, neurologist depending on the nature of usage. This kind of assessment involves series of tasks that is asked to patients to test their cognitive skills (Koo et al., 2019). The test includes different components to be examined such as understanding of language, reasoning and each of them is measured separately with the help of scores and then there is a comparison done with those who have already done their cognitive assessment and is falling under the cognitive performance scale (Beraldo et al., 2019). The main reason for performing the cognitive assessment is if a medical practitioner is concerned in knowing if anyone is experiencing brain injury or stroke or any congenital issue especially in children and this is performed especially after brain surgery to check the mental condition of the patient.
  • The initial stage of this assessment is knowing from the patients about any experience in falling, balance and overall health or any problem with balance or standing.
  • The second step that the medical practitioner performs is to give a set of tasks done to test the strength, way of walking and balance (Cadar et al., 2020).
This assessment helps the medical practitioner to know about any potential risk of falling in future. If the assessment reflects a high potential of falling then the medical practitioner will recommend strategies to prevent the fall so that there are fewer chances of injuries. According to Centres of Disease Control and Prevention and the American Geriatric Society, the fall assessment should be carried out yearly for all adults above 65 years of age. Then a screening needs to be conducted and if the screening suggests that the patient is at risk then the assessment needs to be carried out (Williams-Roberts et al., 2020).

Functional assessment and its purpose

Functional assessment refers to the assessment that is required in determining the person ability to perform certain tasks or certain behaviour. The main reason for performing the functional assessment is to identify the cause of an individual certain behaviour so that there can be effective treatment provided (Masalha et al., 2021). Another reason for which the functional assessment is carried out is to know the reason behind the individual challenging behaviour and the possible circumstances that occurred certain challenging behaviour of the individual. Functional assessment help in evaluating specific things such as grooming, bathing, dressing or evaluating the quality of life.

Question 2

Tools used in Australian Hospitals - Cognitive assessment tools

As per Australian healthcare policy, a cognitive tool should be used across the healthcare facility. The selection of tools should be based on the population target, the time taken to complete the tool and the easiness of the tools (oledano-Shubi et al., 2020). One of the tools used by the Australian Healthcare facilities for cognitive assessment is the Abbreviated Mental Test Score (AMTS 1 and 2) which is used to assess the possibility of dementia in elderly groups. It also sometimes used for assessing mental confusion and other cognitive impairments and is highly recommended to use in cognitive assessment (Monachan et al., 2020). Other cognitive screening tools include

  • Rowland Universal Dementia Assessment Scale (RUDAS 7)
  • The Six Item Screener (SIS -3)
  • Short Portable Mental Status Questionnaire (SPMSQ 6).
  • DRS-R-98 is used for older person with hip fractures.
  • Standardised Mini-Mental State Examination (SMMSE -4)
The Rowland Universal Dementia Assessment scale is used to translate the items or questions into another different language and is recommended to be used with those with a different language and cultural backgrounds (Chen et al., 2020).
  • Falls assessment tools:The Australian Hospitals use the Morse Fall Scale to assess the fall. This scale was developed by Janice Morse in 1985 which assesses the following factors;
    • History of falling
    • Mental Status
    • Secondary diagnosis
    • Intravenous Therapy
    • Use of Ambulatory aids
    • Gait
    In these following factors, each one is rated with yes or no and then a point value is given. The patients are then categorized as high, medium and low risk for fall, depending on the sum of items in the fall assessment test (Zhong et al., 2020).
  • Functional assessment tools The tool that Australian hospital use for functional assessment is the Functional Independence Measure (FIM) which indicates any disability within the patients. It consists of 18 items which are checked against a seven-point ordinal scale where when the score is high, the patients are more able to perform the activities independently and the score range from 18 to 126. The 18 items are then divided into 13 motor items and 5 cognitive items. This scale helps to classify the individual ability to perform the task independently against the requirement of any assistance from another person or another device (de Campos et al., 2020). Also, through this tool, the client status is assessed through By observing the patients on selected tasks that are being given to the patients. The environment of patients such as a home, office or school environment is assessed. There are interviews conducted with the clients or sometimes with the person who takes care of the client. The medical records are checked and opinion is provided based on those medical reports (Goes et al., 2020). Furthermore, the task that is assessed using the FIM tool consists of locomotion, communication, as well as the below self-care tasks;
    • Feeding
    • Bathing
    • Grooming
    • Lower body dressing
    • Upper body dressing
    • Toileting
    The FIM works better for the casual activities or day to day activities of a person and does not considers what the person can do in a given situation (Liqun et al., 2021).

Question 3

The above-mentioned assessments such as cognitive, fall and functional assessments are in some way or other related to the situation of Mr Gun (Ruet & Brochet, 2020). The cognitive functions of Mr Gunn state that he has no worries however he has stress due to his daughter recently diagnosed with cancer, he has the potential of having cognitive issues later in future and to avoid this, a cognitive assessment will be required to perform for Mr Gun so that he does not have any further risk of developing cognitive issues in future. The second assessment of fall assessment will be applicable for Mr Gun as he has recently fallen when he was going in the kitchen. The fall assessment will be performed on Mr Gun with the help of the tool Morse fall Scale in which the factors such as Mental condition, any fall history of Mr Gun, secondary diagnosis of Mr Gun etc will be considered before the assessment. After the consideration of the factors, Mr Gun fall will be assessed by rating the questionnaires with Yes or No and then the value is provided which will help in deciding if Mr Gun possess a higher or lower risk of potential fall in future (Zhong et al., 2020). Since the assessment will be done based on the fall that he has recently faced, the functionality assessment will be another important assessment that will be required to carry out to check if there are no injuries and disability after the fall. In this assessment, the FIM tool will be highly recommended to be used to assess any functionality issue in Mr Gun. As stated above, Mr Gun will be assessed based on 18 items that are mentioned in the scale-out of which 5 cognitive items will be performed on Mr Gun and 13 motor items that need to be assessed to identify if there can be a functionality issue when the fall is repeated (Chen et al., 2020). In case of abnormal findings, it is the nurse who is responsible for the appropriate actions that need to be taken and for this the nurse may communicate the findings to the medical team, different allied healthcare professionals and the in charge of the shifts (Masika et al., 2020).


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