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       When assessing patients, ensure that they are fully informed by explaining the rationale of the assessment and how it will ensure care delivery that meets their individual needs.

       While you may be undertaking an individual assessment, planning care will most likely involve other members of the multidisciplinary team (MDT). Ensure that all members of the MDT are involved that are required, undertaking referrals where necessary.

       Appropriate assessment paperwork.

       Patient’s notes.

       Care planning paperwork.

       This will involve using the relevant assessment documents within your clinical area. The questions asked may reflect Henderson's needs theory (Henderson 1966) (Figure 2.2), Orem's theory of self‐care deficit (Orem 2001) (Figure 2.3), or Roper, Logan & Tierney's Activities of Daily Living model (Roper et al. 1980) (Figure 2.4). All these models focus on the fact that nursing care is provided while the patient cannot self‐care or meet their daily needs.

       The diagnosis involves considering what has been observed and what information has been given during the initial assessment to identify the problem.

       The diagnosis focuses on key characteristics that enable the nursing diagnosis to be made.

       It is the diagnosis, or diagnoses, that inform the care plan.

       More than one care plan may well need to be created to ensure that the patient's individualised needs are met.

       Care plan charts will most likely be available in your clinical area but the key elements to consider are:What is the issue to be addressed?What interventions will resolve this issue?When would be it be appropriate to evaluate care?

       This is your ongoing care for the patient.

       Essentially by performing a thorough assessment, diagnosis and care plan, appropriate, necessary, person‐centred care should be delivered.

       This is when you review the care plan and determine if the initial issue has now resolved, remained the same, or worsened.

       Essentially the evaluation will then lead to an assessment and continuation of the process.

        If the patient becomes unresponsive during initial assessment the BLS (Basic Life Support) algorithm and the A–E (airway, breathing, circulation, disability, exposure) assessment should be used.

        A holistic assessment may take time as well as several discussions, depending on the patient's condition and priorities of care.

      1 Gebbie, K. and Lavin, M.A. (1973). Classifying nursing diagnoses. The American Journal of Nursing 74 (2): 250–253.

      2 Henderson, V. (1966). The Nature of Nursing. New York: Macmillian.

      3 Levine, M.E. (1965). Trophicognosis: an alternative to nursing diagnosis. ANA Clinical Conferences 2: 55–70.

      4 NHS England (2016). Personalised Care and Support Planning Handbook: The Journey to Person Centred Care. NHS England: Leeds.

      5 Orem, D. (2001). Nursing: Concepts of Practice. St Louis: Mosby.

      6 Orlando, I.J. (1961). The Dynamic Nurse‐Patient Relationship, Function, Process and Principles. New York: Putnam Press.

      7 Roper, N., Logan, W., and Tierney, A.J. (1980). The Elements of Nursing. London: Churchill Livingstone.