Importance Of Needs Assessment In Nursing Practice Nursing Essay

Importance Of Needs Assessment In Nursing Practice Nursing EssayConfidentiality and namelessness must be maintained at all times to protect the identity of the service user, cargonrs, families, wellness flush settings and otherwise professionals involved. Any breach of confidentiality will go in an automatic fail.This essay will discuss the greatness of unavoidably pass judgmentment in nursing charge. In relation to topic study 2 about a 68 years old Afro Caribbean retired bus driver male called Carl, who has universe married for 45 years with 5 grown up children and 8 grand children. He smokes 20 a day and enjoys nightcap before pile. His latest brisk signs observation are respiratory 20 rpm, blood contract 168/105, pulse 92bpm, Spo2 95% and BMI 32kg/m2 and he is on statin, betablocker, aspirin, frusemide medication. Currently his wife has notice Carl seems to have forgetfulness, he couldnt remember his way home from the extremely market and documentation losing item s. He is getting frust measured and taking it on his wife and grand children, especially when he canisternot read them a story.This essay will discuss the importance of wishings prisement in nursing practice. It will identify a service users involve base on a scenario and the appropriate judgment tools call for for his care. And from the tools identified, one will be prioritised and apply on his condition. Finally the essay will summarise the experience of using the legal opinion tool and how it will swear out in futurity learning.Patients discernment is the collection of data about an individuals health severalise that identifies and defines longanimous problems in order for solutions to be planned and implemented in line with their preferences (Roper el at 2000 p 124). in that respectfore, a clear idea about health is consequential because this determines which assessment data should be collected. The world wellness Organisation (WHO) (2001) defines health as a stat e of complete forcible, mental and social well existence and not merely the absence of disease or infirmity. Whiles this is a broad definition, it implies that the nursing approach to health care is holistic in nature and therefore health assessments should reflect that philosophy with it focus on the whole person and their context. Nurses are obliged to take in to consideration patient roles physical, emotional, spiritual, social and intellectual needs when making an assessment (Department of wellness 2004). Therefore, when nurses are conducting health assessment on a person it whitethorn requires acknowledgement of techniques of collecting and analysing subjective data which is what the person says about them selfs during history taking. And objectives data which is what nurses observe by inspecting, percussion, palpating, and auscultation during physical examination (Department of Health 2003). Potter and Berry (2005) argue that if inaccurate, incomplete or inappropriate data i s recorded then the everywhereall care of the patient may be affected, including wrong diagnosis and even wrong treatment. NMC (2002), code of professional conduct, urged all nurses to work in a professional manner and suffer by the policies set out by the trust they work in. it bring up that the recording or documentation of information is indispensable and any deviation could turn over to potential consequences for the individual if their standards are not met. The purpose of health assessment is to make judgement or diagnosis because all health treatments and decisions are base on the data gathered during assessment it is paramount that the assessment is factual and complete, providing the foundation for clinical decision making (RCN, 2007). This gathered information provides a omnibus(prenominal) description of the patient. It focuses on the patients needs at that moment in time and possible needs that may need to be addressed in the future (NMC, 2007). Its a f var. and a ccurate account of the individual and their life. Overall assessment is a way of delving deeper into a patients unhealthiness and preventing to a greater extent problems from arising.In relation to case study 2 about a 68 years old Afro Caribbean retired bus driver male called Carl, who has being married for 45 years with 5 grown up children and 8 grand children. He smokes 20 a day and enjoys nightcap before sleep. His latest vital signs observation are respiratory 20 rpm, blood jam 168/105, pulse 92bpm, Spo2 95% and BMI 32kg/m2 and he is on statin, betablocker, aspirin, frusemide medication. Currently his wife has notice Carl seems to have forgetfulness, he couldnt remember his way home from the super market and keep losing items. He is getting frustrated and taking it on his wife and grand children, especially when he cannot read them a story.Newson (2001) suggests that, for a affect to commence a model of assessment is utilised and this model needs to be holistic in all aspect s of patients needs. Therefore proper attention needs to be paid to the biological, psychological and social situations of the patient. It is important that the health assessment includes a thorough examination of the patients activities of daily sustainment (Department of Health, 2002) .The twelve activities of daily living (ADL) are communication, safe environment, breathing, feeding and drinking, elimination, washing and dressing, temperature, death and dying, mobility, working and playing, sexuality and sleep (Roper, Logan and Tierney model 1985). Although, the Roper Logan Tierney model has being criticized for the use of activities of living as a simple dielist and emphasis only on the physical aspect of patient care( Reed and Robins 1991). This contrasts with Newton (1991) who suggests that the description of the Roper Logan Tierney model (1985) have been alter over the years and nominate the model as a system model. Also Pearson (1983) describes it as a systems/developme nt-based model incorporating certain concepts of Dorothy Orems model and the conceptual simulation of Hendersons model (Henderson, 1969). It is important to remember that all ADLs about our individual life activities are interlink and when one or to a greater extent activities is affected receivable to illness then most of the activities can expire compromised. (REF)After a thorough nursing assessment, the ADLs that are appropriate to meet Carls needs are communication breathing, eating and drinking, elimination, safe environment, mobility, working and playing. Communication is essential for make nurse patient relationship (Robinson, 2002). For Carl due to his state of forgetfulness, memory loos, out of character behaviour and thwarting especially when he cannot read for his grand children, he may need referral to see opticians for eye check, and the MMSE tool can be use to assess his state of dementia.Breathing is the first sign every health professional look for during patie nt assessment. beingness able to breathe normally ensures that we can attempt other activities without any difficulties for example running. For Carl his breathing can be affected by smoking for 20 pack years as well as his high BMI can cause shortness of breath. Referral to the NHS stop smoking service or radiographs for chest x-ray to check for infection will be essential. Also continual vital signs check up and the use of the peak flow meter for checking group O level in the lungs or nebuliser will help.Ensuring adequate hydration and nutrition is essential if health is to be maintained and in Carls case he has a higher BMI and he is in a state of confusion. There is a contrariety between dying from nutrition and dying with nutrition. And in Carls case he is dying with nutrition as being over nourished with higher cholesterin level. Fanning H, (2003) suggests that Dehydration as well as UTI can contri stille to his state of confusion. Both the (MUST) tool and the (MMSE) tool for assessment of possible dementia can be used (NICE 2012). Referrals can be made by nurses for Carl to see the dietician and in any case physiotherapist for physical exercise regime and dipstick for UTI.Elimination is very important, and in Carls situation review of his medications will be important since some may cause constipation or frequent urination e.g. furosemide. Higher BMI as a result of being Obese as well as chronic chest problems and constipation can cause urinary incontinent (Kamm, MA1998). Also In male, disease of the prostate may lead to the obstruction of the flow of urine (Abrams el at 2002). The Bristol stool chart can be use to assess constipation, the dipstick tool can also be used to check for infection or UTIs and the fluid balance chart can be use to assess for dehydration by checking input over output.Mobility can be a problem since Carl has a history of forgetfulness and the need to urinate frequently. Fear of not being able to find his way home, been i ncontinence in public and even fear of falling in a new environment may scarce him off from mobilising. Human assistance will be needed as well as the assessment of risk of fall. Carl may need assessment on Working and playing since he is retired, have memory injury and get upset when he cannot read for his grand children. Socialisation seems impossible for him now due to his condition. Referral to psychologists for self worth exercise and also going to day centres to meet other large number will help.According to the RCN (2004), nurses will always need an assessment tool to guide their daily nursing practice in terms of their professional accountability and responsibility. For any tool to be effective it must be integrated into daily activity as a standalone initiative it is unlikely to have a signifi toss feign.In Carls condition the as human beings the capacitor to sustain life is dependent on our ability to address biological needs including breathing, maintaining blood fl ow to all our major organs, eating and drinking, elimination waste, protect ourselfes from injury or disease, exerciseing and resting. All these activities can be monitored through nursing observations of patient in our care, enabling us to decide whether any intervention is necessity to help them maintain their vital portions. In order to make accurate observations we need to learn the correct techniques and how to use relevant equipment. To appreciate the significance of the observations, we need a good understanding of relevant anatomy and physiology, and how to distinguish normal from abnormal functioning. We then have to decide whether our observation require further action, which dexterity include double checking results, increasing the frequency of observations, reporting changes to the clinical managers,Universal Screening Tool (MUST) will be appropriate for his health. The reason being that, been over angleiness down or having a higher BMIcontribute to a whole range o f health problems such as embrace conditions, high blood pressure, type 2 diabetes, stroke, sleep apnoea, cancer, gallstone, weak pelvic muscles and osteoarthritis (Department of Health, 2004). Heart disease for instance, is one of the most widespread main health risks of being overweight. organism overweight maturations the fortune of warmheartedness malfunction and blood circulation problems and may result in congestive heart failure (Miller el at 2006). He continued that, losing weight in this situation may not only avoid the above-mentioned ailments but as well assist normalize blood pressure, cholesterol levels and triglyceride and diminish turmoil in the body.According to Elia, (2003) MUST is a screening tool that has been devised for application to all adult patients across all health care settings. Malnutrition indecently affects physical and psychological function (Elisa, 2000 Stratton et al. 2003b) and impairs patients recovery from disease and injury, thereby incre asing morbidity and mortality.BMI (body mass index) is an easy, inexpensive method of predicting the percentage of your body weight that is due to fatten mass. BMI is found by dividing your weight (in lbs.) by your height squared (in inches) and then multiplying by 703. In adults, a BMI below 18.5 is considered underweight, 18.6 to 24.9 is considered healthy, 25.0 to 29.9 is considered overweight and above 30.0 is considered obese.Respiratory function has been studied extensively in relation to BMI. For those with lung diseases, including emphysema, chronic bronchitis, asthma, and interstitial and vascular lung diseases, respiratory function is moderately to severely compromised. This compromise can be exacerbated by being overweight or having a BMI over 25.0. However, even in those with normal airway function, high BMI can impair respiratory function. corpulency and inveterate Obstructive Pulmonary Diseases (COPD)Chronic Obstructive Pulmonary Diseases include emphysema, chronic br onchitis and asthma. COPD causes a settle in elastic recoil of the lungs so that excess air becomes trapped in the chest. This stretches the muscles involved in respiration and compromises their function. The respiratory muscles must then work harder even at rest, increasing oxygen demand on an already taxed respiratory system.At a certain point during physical activity, COPD patients reach a level when add-ond effort does not further increase the amount of air that they can expire. Having a high BMI means having more weight for your muscles to support during mobility. Thus, if you have COPD, the level at which increased effort no longer provides an increase in expiration comes much faster since you are working harder to support your own weight. In addition, having a high BMI means having more weight on the chest for the respiratory muscles to work against.Sponsored LinksLose 2 Stone in 4 Weeks?Mom reveals the shocking truth more or less the UKs hottest dietwww.constant-fitness.com /dietUnderweight and COPDAlthough a high BMI can further impair respiration in those with COPD, once COPD progresses to a severe level, weight loss becomes problematic. Because of discredit oxygen levels in the blood, blood becomes shunted from the abdomen into the heart and lungs. This causes malnutrition because the gut is not getting enough blood flow to properly digest foods. Additionally, severe impairment of the lungs causes the respiratory muscles to work so much harder that metabolism greatly increases, even at rest. Typically, severe COPD patients who are underweight have a worse outlook than those who are overweight because they are essentially starving.High BMI in Healthy IndividualsAccording to a 2005 study by Jones et. al., high BMI can severely impact respiratory function even in non-diseased individuals. The study found that two Functional ease Capacitythe volume of air in your lungs after passive exhalationand expiratory Reserve Volumethe volume of air you can ex pire after passively exhalingdecreased exponentially as BMI increased. Subjects who were morbidly obese were actually breathing close to their Residual Volumesthe amount of air in your lungs after forced exhalation. Another 2005 study by Medarov et. al. Supports Jones findings and also found that Total Lung Capacitythe maximum amount of air you can inhaledecreased with increasing BMI.According to the American College of Sports Medicine, being overweight has mechanical effects on respiration, due to increased weight on the chest wall and diaphragm. universe overweight also causes an increase in zippo use at the same workload compared to a leaner person, so the respiratory muscles fatigue at lower intensities in heavier people. These effects may contribute to the decreases in Functional Residual Capacity, Expiratory Reserve Volume and Total Lung Capacity.Lung Diseases Caused by ObesityThere are two types of lung disease for which obesity is a primary cause. The first is Obesity Hypo ventilation Syndrome, also known as Pickwickian Syndrome. Obesity Hypoventilation Syndrome involves chronic hypoxemiatoo little oxygen in the bloodand hypercapniatoo much carbon dioxide in the blood. The second lung disease obesity can cause is Obstructive Sleep Apnea. This disease involves periodic airway conk out and increased airway resistance during sleep. As both of these diseases progress, pulmonary hypertension may occur and eventually cause cor pulmonalefailure of the right side of the heart.Domino military groupBecause high BMI decreases lung function in both diseased and healthy individuals, an unfortunate domino effect frequently occurs. Since being overweight makes it harder to breathe, those with respiratory problems may become less physically active. Decreased physical activity causes your muscles, including your respiratory muscles, to weaken and break down, which in turn makes breathing even more difficult. A descending(prenominal) spiral begins, in which inactiv ity begets further respiratory problems and respiratory problems beget more inactivityRead morehttp//www.livestrong.com/ obligate/84685-bmi-respiratory-function/ixzz2I54s1yvbThe Health Risks of Overweight and ObesityDr Jeremy SimsMB BS MSc MRCGP FRIPH FRSH PGDipHI DipNH MRNTObesity isnt just a cosmetic problem its very much a health problem as well. You may be reading this today because you are, or have been, very unhappy about your physical appearance.However, losing weight isnt just about looking good, it is about public opinion good its about being healthy and living a productive and comfortable life. Above all, it is about avoiding the terrible health consequences of branding around excessive weight.The growing evidence shows that if you are overweight you are more likely to develop health problems, such as heart disease, stroke,diabetes, certain types ofcancer, gout (joint pain caused by excess uric acid), and gallbladder disease. Being overweight can also cause problems such as sleep apnoea (interrupted breathing during sleep) and osteoarthritis (wearing away of the joints) and the more overweight you are, the more likely you are to have these health problems.In comparison, healthy and steady Weight Loss can help improve the poisonous effects of being overweight. The latest studies show that by losing as little as 10 to 20 pounds you can dramatically improve your overall health status, whilst significantly diminishing your risk of disease.The Risks To Your HealthHeart Disease and StrokeHeart disease and stroke are the leading causes of death and disability for both men and women in the occidental World. Overweight people are more likely to have high blood pressure, a major risk fixings for heart disease and stroke, than people who are not overweight. Very high blood levels ofcholesteroland triglycerides (blood fats) can also lead to heart disease and often are linked to obesity. Being overweight also contributes to angina (chest pain caused by decr eased oxygen to the heart) and sudden death from heart disease or stroke without any signs or symptoms.The good news is that losing a small amount of weight can reduce your chances of ontogenesis heart disease or a stroke. See dietitian, Juliette KellowsHealthy Heart Dietfeature.Reducing your weight by 10 percent can decrease your risk of developing heart disease by improving how your heart works, reducing your blood pressure, and reducing the levels of blood cholesterol and triglycerides.DiabetesNoninsulin-dependent diabetes mellitus (type 2 diabetes) is the most common type of diabetes in the Western World. Type 2 diabetes reduces your bodys ability to assert blood sugar. It is a major cause of early death, heart disease, kidney disease, stroke, and blindness.Statistically, overweight people are twice as likely to develop type 2 diabetes as people who are not overweight.You can reduce your risk of developing this type of diabetes by both losing weight and by increasing your physi cal activity.Furthermore, if you have type 2 diabetes, losing weight and becoming more physically active can help control your blood sugar levels. If you use medicine to control your blood sugar, Weight Loss and physical activity may make it possible for your family doctor to decrease the amount of medication you needMohammed, MA (2009) Improving accuracy and efficiency of early warning scores in slap-up care. British Journal of Nursing. 18(1) 18-24This article is a report on an experimental study to compare the effectiveness of hand held early warning computer system with the traditional pen and publisher methodArticle 2.Johnstone C, Rattray J and Myers L (2007) Physiological risk factors, early warning systems. British Association of Critical Care Nursing. 12(5) 220-231This article is a ecumenical article that provides underpinground information on the topic of why early warning systems can improve patient careArticle 3.Hughes LL (2009) Implementing a patient assessment framew ork in acute care Nursing Standard 24(3) 35-39This article describes a service improvement initiative to improve patient assessment using an early warning score system over a4 month period at a Hospital in BirminghamArtcicle 6Wheatley I (2006) The nurses practice of taking level 1 patient observations. Intensive Critical Care Nurse 22(2) 115-21This was a survey conducted to discover the nurses practices of taking clinical observations in acute settings. It uses an observation data collecting tool (words 470)Read morehttp//www.ukessays.com/essays/nursing/examining-use-of-early-warning-scores-in-assessment-nursing-essay.phpixzz2I5R87ePnRead morehttp//www.ukessays.com/essays/nursing/examining-use-of-early-warning-scores-in-assessment-nursing-essay.phpixzz2I5QcaLArWeight-control Information Network.Do You Know The Health Risks Of Being Overweight?. Nov. 2004. U.S. Dept. of Health and Human Services. 23 Oct 2006Diabetes Statistics.Total Prevalence of Diabetes Pre-diabetes. 2005. America n Diabetes Association. 23 Oct 2006The Nutrition Source.Healthy Weight. 2006. Harvard School of Public Health. 25 Oct 2006Obesity causes many another(prenominal) of the most common diseases in the world. Being overweight can cause insulin resistance, which leads to Type II Diabetes. A diet high in fat and overleap of exercise causes cardiovascular disease and congestive heart failure. Excess weight can cause sleep apnea and respiratory illnesses. Many top scientists believe the increase of average weight directly corresponds to the increase of cancer cases, including kidney, breast, colon and prostate cancers.Read moreEffects of Being Overweight eHow.comhttp//www.ehow.com/about_4596213_effects-being-overweight.htmlixzz2I57jKX6tAdvances in the recording of vital signs make it possible for nurses to monitor patients continuously, be it their heart function, arterial blood pressure, central venous pressure or oxygen saturations. The recordings generated by this equipment must be int erpreted according to the patient and in conjunction with other observations. The concern is that nurses may become too reliant on using technology to carry out assessment. Burman et al (2002) describe how staff who are used to equipment can feel insecure assessing patients without this equipment to validate their findings.Within the competencies are skills such as venepuncture, cannulation, arterial blood gases (obtaining and analysing), and recording and obtaining ECGs. Docherty (2003) identifies the recording and interpretation of the 12-lead ECG as being pivotal in the assessment and management of patients who are experiencing chest pain. This is further back up by Harvey (2004) who discusses the assessment and management of patients suffering from angina. However, it is further complemented by accurate physical assessment of the patient.Basic is a term that is frequently used to describe blood pressure, pulse, respiratory rate and temperature. However, I would argue that this undervalues these observations. Breakell (2004) identifies respiratory rate as one of the most important signs and yet one of the most frequently omitted clinical observations. Carberry (2002) also found this to be a problem in clinical practice.The objective of observation is to monitor patients progress, thus ensuring the prompt detection of adverse events or delays in recovery (Stevenson, 2004). Respiratory rate is pivotal to assessment. Many scoring systems incorporate respiratory rate, such as APACHE Acute Physiology and Chronic Health Evaluation Score SIRS Systemic Inflammatory Response ScoreAssessment toolsNeiderhauser and Arnold (2004) identify the importance of assessing the health risk status of patients, and the indications for intervention. A wide build of assessment tools are in use to facilitate assessment and ensure the reliability of the process.For example the EWAS/MEWS tool can be use to check vital signs and avoid patients deterioration. EWAS is use for the ass essment of unwell hospital patients, using 5 simple physiological parameters, mental response, pulse rate, systolic blood pressure, respiratory rate and temperature.It scoring system can be calculated at the patients bedside, using a simple and inexpensive equipment to measure any parameters. Of all the parameters respiratory rate is said to be the most sensitive indicatory of a patients physiological well being. Breakell (2004) identifies respiratory rate as one of the most important signs and yet one of the most frequently omitted clinical observations. Carberry (2002) also found this to be a problem in clinical practice. This is logical because respiratory rate reflects not only respiratoryfunction as in hypoxia or hypercapnia, but cardiovascular statusas in pulmonary oedema, and metabolic imbalance such as that seen in diabetic ketoacidosis (DKA)( REF).Department of Health (1999b) Making a DifferenceStrengthening the Contribution of Nurses, Midwives andHealth Visitors. DH, Londo nthe health problems that stem from being overweight go way beyond the ones we usually hear about, like diabetes and heart disease. Being overweight can also affect a persons joints, breathing, sleep, mood, and energy levels. So being overweight can impact a persons entire quality of life.Dangers of being OverweightSome of the dangers of being overweight include developingHigh Blood PressureWhen you have excess body fat, your body retains sodium. When your body retains sodium, blood volume increases and blood pressure rises. High blood pressure causes your heart to work harder, which is dangerous for the heart.DiabetesObesity is the leading cause of type 2 diabetes. Excess fat makes your body resistant to insulin. When your body is resistant to insulin, your cells cant get the energy they need.StrokeAbnormal blood fatsA diet high in saturated fats increases the level of LDL (bad) cholesterol.OsteoarthritisExcess weight adds pressure to joints and wears away at the cartilage that pro tects them.Sleep apneaThe more overweight a person is, the greater more severe the sleep apnea will be. pubic louseMen and women who are overweight have a higher risk of developing many different kinds of cancer.GallstonesGallstones are more common in people who are overweight. The connection between gallstones and weight is unclear.Weak Pelvic MusclesPhysical Discomfort As fat accumulates, it crowds the space occupied by yourorgans. People who are overweight may have difficulty breathing, walking or sitting.Heart disease is 1 of the most widespread main health risks of being overweight. Being overweight to a great extent increases the probability of heart malfunction and blood circulation problems and may result in congestive heart failure, heart attack, angina (chest pains), abrupt cardiac arrest or unequal heartbeat. Weight loss in this situation may not only avoid the above-mentioned ailments but as well assist normalize blood pressure, cholesterol levels and triglyceride and di minish inflammation in the body.Cancer is one of the foremost causes of death in the unify States, and is frequently a result from fat cells that affect cell growth and multiply beyond capacity. Colon, esophagus, and the kidney are the most affected regions of the body. Being obese has also contributed to uterine as well as postmenopausal breast cancer in females.Sleep apnea, Osteoarthritis plus other Health DifficultiesIn sleep apnea the sufferer experiences short lapses of breaths during nighttime. This in turn makes the person tired right through the day, making it hard for him to concentrate on work. In some cases, heart failure has also been noted in patients suffering from this ailment. The lapse of breath happens due to the increased size of the cells of the neck, obstructing the windpipe at certain intervals. Dropping weight may decrease the size of the neck and diminish the pressure on the windpipe and make breathing easy.Osteoarthritis is another health risk of being over weight. In this particular ailment, the joint bone and the tissue that protects joints (cartilage), wear away. The joint bone of numerous parts of the body like the hip, knees, plus lower back are the main targets of Osteoarthritis. Being overweight places a lot of heaviness on the joints, which might lead to this condition in the long run. Droppingweightwill let down thebody fatand lessen the aches and pains.Excess fat accumulates in the liver cells and causes the organ to inflate, leading to injuries. This results in Fatty colorful diseases. This disease can lead to severe liver injury, built-up of scar tissue that blocks the proper blood flow to the liver (cirrhosis), and complete liver breakdown. It is relatively quasi(prenominal) to alcoholic liver damage but does not inevitably mean that it cannot affect those who do not consume alcohol.Taking communication for instance, it is essential for building nurse patient relationship (Robinson 2002). It is important, for example fo r nurses to know during assessment whether a patient can hear, understands the language in which a question is being asked or can answer by speaking or sing language. And if they cannot hear, do they wear hearing aids, if so in which ear. Language barrier can be a major problem during assessment, but interpreters, family and friends can contribute and help. However, very often accurate information will not be given, preventing full assessment of patients needs. The use of braill and flashy lights is also important during assessment for patients who are blind or deaf.Newton (1991) suggests that descriptions of the Roper, Logan and Tierney model (1985) have been varied over the years. The model has been depict as a system model (Aggleton Chalmers, 1987), as a model that incorporates multiple theories (Thibodeau, 1983) and as an activities of living model based on human needs (McFarlane, 1980). Farmer (1986) has described it as having a functional approach. Pearson (1983) describes i t as a systems/development-based model incorporating certain concepts of Dorothy Orems model and the conceptual framework of Hendersons model (Henderson, 1969).It seems fair to suggest that the Roper, Logan and Tierney model has had criticism over time. Indeed, the model has been criticized for the use of the activities of living as a simple checklist (Reed Robbins 1991), the emphasis on solely the physical aspects of patient care (Minshull et al 1986, Walsh 1989), and the simplicity of the model (Walsh 1991). Bellman (1996) suggests that the first two problems indicate an inappropriate introduction and implementation of the model in practice.We have done nursing assessment and for Carl the ADLs that are a