In the first step of the Tanner (2006) model nurses use their personal knowledge and experience to notice whether the patient requires attentions based on their expectations and looking at environment of the patient. Therefore, for an experience nurse it is easier for them responding to the similar situation if she or he revisit because the knowledge is already there through experience. In the case of Mr Devi, assessment will perform using systematic assessment based on the ABCDE approach (Airway, Breathing, circulation, Disability and Exposure). The ABCDE approach is an evidence-based practice widely accepted and used by all the members of a multidisciplinary team (MDT) to assess an acutely ill patient (Harrison and Daly 2011). First, life-threatening …show more content…
Pulse oximeter used to check his oxygen saturation level, which was 98% on air with no central or peripheral cyanosis. Since Mr Devi, does not seem to have any sign of abnormal respiration. The next assessment is circulation, where there are many physical signs to look for. The colour of the hand and digits, are they blue, pink, pale or mottled. Also need to measure for capillary refill time (CRT) by applying cutaneous pressure for 5 Sec on a fingertip held at heart level of Mr. Devi. The normal value of CRT is usually less than 2 second prolonged CRT suggests poor peripheral perfusion. Measure his Blood Pressure (B/P), count pulse rate by listening to the heart with a stethoscope or palpate peripheral and central pulses, assessing for the presence, rate, quality, regularity and equality. All of this assessment indicates the cardiovascular system in the patient is within the normal range or is there any emergency measures should take (Resus.org.uk 2016). However, Mr Devi’s circulation is a concern because his HR was 110bpm which is higher than normal range, the normal heart beat for adults ranges from 60-100bpm. Also his BP was 190/99mmhg with mean arterial pressure (MAP) of
Through basic observations, health professionals are able to evaluate the performance of an individual’s health status. In relation to Casey, it is noted in her Observation Chart that in the time span of two hours the patient’s health status had changed from being relatively normal (to the patient) to an increased respiratory rate, heart rate and temperature as well as a decrease in blood pressure. It is also noted that the patient has a score of 8 in the pain scale (compared to the score of zero two hours previously), relating to the lower abdomen. Programs such as Between the Flags acknowledges the fact that the early recognition of deterioration of patients can reduce harm to patients through designing and implementing systems which provide a structural response in the event of a deteriorating patient, such as Rapid Response and Clinical Review. There are two phases involved in the rapid response, which includes the afferent phase and the efferent phase. The afferent phase focuses on the overall monitoring and recognising the deteriorating patient whereas
In this Assessment nursing course, one of the major things that is taught is the most important part of giving proper care to a patient. Correct patient assessment is needed before any nursing care plan or treatment can be implemented. This post-review of a person’s assessment will demonstrate the proper way to go about assessing a person’s health.
Orem’s Self-Care Model (2001) was developed by the American nurse Dorethea Orem and is very person centred by concentrating on what the patient is able to do independently and focussing care around that aspect (Barratt, Wilson and Wollands, 2012). However, it has been criticised for the use of complex language, terminology and concepts (Murphy, Williams and Pridmore, 2010). RLT was used in this case due to Susan’s main concern of shortness of breath (SOB) affecting all her AL and is the sole model used on the admitting ward and local NHS trust admittance paperwork.
The purpose of this paper is to conduct an in depth exploration of the nursing care considerations of patients in a specific clinical area. Through the synthesis of prior knowledge, clinical experiences and skills, evidence based best practices, and care of patients a comprehensive care and teaching plan will be composed. Integration of critical thinking and clinical reasoning skills, combined with evidence-based research will provide confirmation of nursing process comprehension. The inclusion of reviewed literature will further support knowledge and understanding.
The first stage of the process is assessment. Roper et al (2001) refer to this process as ‘assessing’ indicating an ongoing activity; this encourages nurses to recognise the on-going nature of this initial phase. The assessing stage includes gathering information about a patient, reviewing this information, identifying actual and potential problems and prioritising (Roper et al 2001). Roper et al (2001) explain the importance for assessing, as early as possible in the patient’s stay. Extensive, in-depth information may not be gathered on an initial assessment, however any information obtained contributes towards individualised care (Roper et al 2001). Ambrose and Wittig (1998) explain that the initial assessment becomes a foundation for ongoing assessing and holistic care. Barrett, Wilson and Woollands (2009) concord with Roper et al and Wittig in that assessing is an ongoing process and elaborate on this explaining that assessment should not be confused with admission. They state “an admission tends to be a one-off process when you first meet the patient, whereas assessment carries on throughout your relationship with the patient” (pg22). Assessment enables the nurse and patient to identify actual and potential problems. Although, some problems can be directly related to biological needs, holistic needs must be considered, i.e. psychological state and cultural/social standing
This essay will now analyze the nursing intervention that requires for the acutely ill patient to prevent an exacerbation of chronic obstructive pulmonary disease. The nurse carried out an initial assessment of a full history, taking in consideration that the patient was over 35 years of age who has been, or still is, a cigarette smoker, with vascular related diseases and had symptoms of breathlessness on exertion, chest tightness, wheezing, coughing, sputum production especially in the morning and chest infection (Currie 2009). A physical examination was done to check the patient respiration rate, depth and rhythm, blood pressure, pulse, temperature and oxygen saturation (Lynes 2007). The acutely ill patient’s respiration was between 30-34 breaths per minute, blood pressure 580/98, pulse 110 beat per minute and saturation levels 80-82%. Increase respiration indicates that the patient was in fear, pain and anxious. Anxiety causes stimulation of sympathetic nervous activation which forces bronchioles
The knowledge of nursing sensitive indicator can be helpful in providing the patient care which meets the quality and ethical standards. Nursing sensitive indicators rely on evidence to take patient care decisions (Patrician, 2010). According to Patrician (2010), Evidence Based Nursing is the use of personal expertise and research to take decisions on patient care. In case of Mr. J, there is a clear lack of evidence based nursing. Mr. J was kept in restraint without considering that Mr. J was not trying to get out of bed by himself. When the pressure ulcer was identified, the nurse
An evaluation of Mrs Smith circulation was the next step carried out by the nurse, as in the breathing assessment Mrs Smith pallor was noted as being flushed and the patient appeared confused this could be associated with poor cardiac output. The nurse recorded the patient’s blood pressure using a dinamap it was measured at 88/50, it was then rechecked manually to ensure accuracy. The pulse was checked manually for rate and rhythm it was recorded as 98 beats per minute. Capillary refill was checked, was found to be normal.
The pulse is an indication of an individual’s heart rate. When checking for a pulse in the primary survey, begin with palpating the patient’s radial or carotid artery (Basic Patient Care 2012, p. 50). This may reveal a normal (60-100 beats/min), tachycardia (<100 beats/min), bradycardia (> 60 beats/min) or asystole heart rate. Additionally, the capillary refill may also provide details about a patient’s cardiovascular status. This is performed by applying pressure to the nail bed and calculating the time it to takes to refill to a normal color, which should take no more then a few seconds otherwise suggesting capillary closure (Mick J Sanders, 2012, p. 1400). An additional accessory to Circulation is Hemorrhages, these involve more through examinations of the pulse, blood pressure and warmth of peripheries of patients. Additionally, you must thoroughly look for indication of bleeding, specifically in the areas around the chest, abdomen and externally seen by the eye.
With the health care system changing so rapidly, it is important that nurses are autonomous. It is necessary, as patient advocates, that we understand the cause and effect of all entities involving our patients. Critical thinking and making the correct judgment call clinically is vital. A patient situation which comes to mind is an 86 year old female, weighing 50kg, Vital Signs: Blood Pressure: 80/50, Heart Rate: 102 (Sinus Tachycardia), Respirations:
It is crucial to act upon findings present in the A-E assessment, but also to ensure the stability and safety of the patient by monitoring the patient for the continuing time of care, such as 24 hours for Colin.
It is during the second phase that the nurse must establish a nursing diagnosis. Only diagnosis approved and listed through The North American Nursing Diagnosis Association (NANDA) may be used. Ineffective airway clearance, risk for impaired skin integrity, risk for infection and ineffective coping are just a few examples of NANDA approved diagnosis. A nursing diagnosis is a clinical judgment about actual or potential individual, family, or community experiences/responses to health problems/life processes. A nursing diagnosis provides the basis for selection of nursing interventions to achieve outcomes for which the nurse has accountability (Defining the Knowledge,” 2012).
This assignment will present a nursing care study of a patient on a cardiac ward. The patient will be referred to as Ann to maintain confidentiality (NMC, 2008). Ann’s consent was gained prior to starting this care study. The care study will be developed using the Nursing process and the Roper, Logan and Tierney model. These will both be outlined. The assignment will focus on the assessment process and one problem identified during the assessment and the nursing care which followed this.
ABC Financial Services has come under scrutiny, with an investigation by the Securities and Exchange Commission, resulting in the dismissal of the CEO for both legal and ethical violations. Edit consulting has been tasked with the creating a project to analyze and address the issues plague ABC Financial Services. The investigation, the legal and ethical transgressions and the actions of the CEO has fractured the morale and confidence with both employees and consumers alike. Edit consulting will develop and implement strategic objectives and goals, providing education, coaching, and continual improvement protocols. Edit Consulting, will complete an analysis of the staff, management, and daily operations, will empower the
A patient experiencing ARDS requires extensive ongoing nursing management. Some treatments anticipated would be treating the underlying causes, promoting gas exchange, supporting tissue oxygenation, and preventing complications (Urden et al., 2014, p. 523). Some nursing interventions can focus on optimizing the oxygenation by positioning the patient in a prone position (Urden et al., 2014, p. 524) as it is shown to improve the oxygenations in patient with ARDs. Also frequent reassessment of secretion clearance and suctioning the patient to assist with the pulmonary edema the patient is experiencing. Another medical management is administering medications as orders and utilizing PRN medications such as bronchodilators to facilitate the decrease