In this assignment we will discuss the holistic assessment process on admission to the clinical area and the duties that the nurse has throughout this process. We will also consider the medical conditions Mr C is presenting with and the appropriate care the nurse should provide relating to specific conditions. We will also discuss the pathophysiology of each of his conditions. Within the assignment we will discuss the post-operative care Mr C will be given by the nurse and the reasoning for this care. Including airway and breathing, circulation, pain management and psychological care. Whilst still in the clinical area we will explore the process of discharge planning and the role of the nurse throughout this process. Lastly we will …show more content…
The nurse needs to make sure they remain nil by mouth. However, it is also the nurse’s responsibility to monitor the patient’s blood glucose levels as they have type two diabetes. The nurse should also enquire if the patient has any eating preferences, for example do they require any religious, any allergies or are they vegetarian?
Another assess that the nurse should undertake is elimination. Bowl movements should be documented, as things may have changed since the handover from A&E took place. Mr C has experienced some confusion, the nurse should also ask if has had difficulty urinating, pain or burning. Collecting a mid-stream urine (MSU) may also be an idea to check for urinary tract infections (UTI’s).
There are many other activities of daily living the nurse should assess during their initial assessment of the patient such as washing and dressing controlling temperature, mobilization, working and playing, expressing sexuality, sleeping and death and dying. These are also all very important to assess however some may be difficult to assess until you have witnessed the patient doing them (Hollnd 2005).
As Mr C is due to undergo a surgical procedure an assessment of his observations should be carried out including a respiratory function. The nurse should ask the patient if he has a history of respiratory illness and if so how it was treated. He should also be asked if he has any productive coughs. An assessment of blood pressure, pulse and oxygen
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
The function of assessment in learning and development is primarily to provide a measurable barometer for the students progress.
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.
T.C. has now been admitted to your unit after an exploratory laparotomy. Vital signs (VS) are 130/70,
This assignment shall focus on a patient called Audrey Smith, a 75 year old lady who has been transferred to the ward from the emergency department with a fractured neck of femur, small haematoma to the left forehead, soft tissue injury and bruising to the left shoulder following a fall at home involving her dog. On admission to the ward at 14.00 hours, Audrey has an intravenous transfusion in progress, an indwelling catheter insitu, she is alert and orientated to time and place and is responsive with a GCS of 14. The plan is for Audrey to go to theatre for arthroplasty of left hip at 17.00 hours. She is nil by mouth and requires hourly neurological observations. The author shall discuss the holistic nursing interventions Audrey shall receive to ensure she is safe, her hygiene and comfort, elimination and nutritional needs are met.
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 assignment will reflect on the effectiveness of my clinical and interpersonal skills in relation to my position as a nurse in a busy critical care unit. It will primarily focus on one particular patient and the care they received by myself in their immediate post operative period. In accordance with the NMC’s code of professional conduct names will not be used to protect the patient’s confidentiality. NMC (2008).
John was a 76 year old gentleman returning to an orthopaedic ward following a total hip replacement under general anaesthetic. The agreed care plan was to regularly monitor John’s vital signs over the next several hours in accordance with local hospital resuscitation trust policy (2012) and the National Institute
The nurses were required to attend to the personal needs of the patients by asking if they want to use the bathroom or bedpan and any other needs that the patients want to be attended to. In addition to the above, the nurses check position and ask patients if there is anything he or she could do to make his or her positioning comfortable. These include identification of risks for skin breakdown and attending to such risks by providing hygiene and skin care.
The patient on which the care plan will be assessed will be a 72 year old female, May Watters who I assisted in the care of during clinical placement in the Emergency Department (ED). May Watters is a pseudo name to ensure confidentiality to An Bord Analtrais standards (ABA 2000). May was brought in by ambulance which was called by her husband Jimmy. May was brought into the ED for Diarrhoea and Vomiting 5/7 days and generally unwell and weakness and non productive cough. Mays’ husband who is her next of kin was concerned about her deterioration
Respiratory Assessment for Nurses outlined the importance of appropriate respiratory assessment to improve care outcomes for the acutely ill ward patient. It is recognized that deterioration in physiological status is often not appreciated, nor acted on in a timely manner (Considine and Botti 2004). The anterior posterior diameter of the chest has a ratio of 1:2. Normal breathing is silent, regular, symmetric, and rhythmic and occurs at a rate of 12 to 20 times per minute (Jarvis, 20 The 4 major components of the lung exam (inspection, palpation, percussion and auscultation). Learning the appropriate techniques at this juncture will therefore enhance your ability to perform these other examinations as well. A student nurse completed a
After surgery, Mr. Baker is taken to a room on the medical-surgical floor. He has an IV infusing at 125 ml/hr, a PCA pump, and a nasogastric tube connected to low suction. He is receiving oxygen through a nasal cannula.
In the professional setting, knowing the patient through his or her diagnosis, name, history of present illness, laboratory results or reason for staying in the hospital only contributes to the manner of physical care of the patient. However, recognizing the patient 's spiritual needs such as emotional support, mental positivity, and intellectual understanding of his or her situation gives a better assessment, as well as a trusting relationship between the nurse and the patient, as per personal experience. In the ward, it is evident that most of the staff nurses spend their time doing documentations, preparing medications, following-up laboratory requests, as well as reading through the patients ' charts to affirm the physician 's order. Throughout the duration of our shifts as student nurses, I see that the most that the staff nurses get to be conversant with the patient is when certain procedures (such as feeding through nasogastric tube, taking
Assessment of a patient is a big process of decision making, it is about the collection of information which will contribute to an overall judgement of a person and the illness they may have. Lloyd (2010) states that assessment is one of the first steps which is needed to be done in the nursing process, it is a building block for a relationship and an ongoing process which lets health professionals gather the correct information to help them understand the problems and needs that the patient is going through. Most of the nursing assessment which are in use today will all have very similar aims. The difference is that how the assessment’s are carried out is where the differences come from.
Assessment in the nursing process will establish the patients' ongoing needs and provide a quality of care best suited to the individual, to achieve a desirable health outcome.