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Quation for nursing assessment
Study guide for nursing assessment
Quation for nursing assessment
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Patients often have complex care needs, and often present with multiple co-morbidities or problems. The process of conducting a comprehensive nursing assessment, and the coordination of care based on these findings is central to the role of the Registered Nurse (NMBA 2006). Evidence-based interventions must then be planned and implemented in a patient-centred approach in order to achieve agreed treatment goals and optimise health (Brown & Edwards 2012).
Part I: Identification of Health Issues and Preliminary Prioritisation Mr Cooper has presented to the emergency department following the development of a productive cough and increased shortness of breath on a background of chronic obstructive pulmonary disease (COPD). His vital signs are
R.S.’s clinical findings as a consequence of his chronic bronchitis are likely to include: being overweight, experiencing shortness of breath on exertion, producing excessive amount of sputum, having a chronic productive cough, as well as edema and hypervolemia just to name a few. (Copstead & Banasik, 548) Some of these signs and symptoms would be different if R.S. had emphysematous COPD. In emphysema (or “pink puffers”), there is weight loss, the cough is absent or negligible, and edema is not present. While central cyanosis and jugular vein distention are present in late chronic bronchitis, these pathologic manifestations are absent in emphysema. . (Copstead & Banasik, 549)
R.S. has chronic bronchitis. According to the UC San Francisco Medical Center “Chronic bronchitis is a common type of chronic obstructive pulmonary disease (COPD) in which the air passages in the lungs — the bronchi — are repeatedly inflamed, leading to scarring of the bronchi walls. As a result, excessive amounts of sticky mucus are produced and fill the bronchial tubes, which become thickened, impeding normal airflow through the lungs.” (Chronic Bronchitis 2015) There are many things that can be observed as clinical findings. R.S. will have a chronic cough that has lasted from 3 months to two years or more, and a lot of sputum. The sputum is due to
Respiratory assessment is a significant aspect of nursing practice. According to the National Institute for Health and Care Excellence, respiratory rate is the best indicator of an ill patient and it is the first observation that will demonstrate a problem or deterioration in condition (Philip, Richardson, & Cohen, 2013). When a respiratory assessment performed effectively on a patient, it can result in upholding patient’s comfort and independence in progress of symptom management. Studies have acknowledged that in spite of the importance of the respiratory rate (RR) it is documented rarely than the other vital signs in the hospital settings (Parkes, 2011). This essay will highlight the importance of respiratory assessment and discuss why nurses
The purpose of this essay is to explore nursing care priorities for a patient with a common health condition. A common health condition is a disease or condition which occurs most often within a population. The author has chosen scenario 3 for this essay and will describe the nursing assessment and care planning provided to a patient with Chronic Obstructive Pulmonary Disease (COPD). The WHO definition of COPD is a lung disease which has a chronic obstruction of the airways that impedes normal breathing and is not fully reversible (). According to), there are estimated to be over 3 million people in the UK with COPD. It is common in later life and there are approximately 25,000 deaths each year, with 15% of COPD being work related (The identity of the patient will remain anonymous in adherence with the Nursing and Midwifery Council, Code of Conduct on patient confidentiality (). However, the patient will be referred to as Mr B in this essay. The author has chosen the priority of eating and drinking for Mr B. Patients with COPD are at increased risk of malnutrition and nurses must make certain they screen patients and offer advice or refer as necessary (). If this priority is managed well it will have a positive effect on the other priorities (, 2012). In accordance with NICE Guideline 101 (), the treatment and care provided should consider each persons’ individual requirements and preference. Care and treatment should take into account people’s individual needs and choices. To allow people to reach informed decisions there must be good communication, supported by evidence-based practice (). This essay will provide an evidence based discussion on how care will be implemented in relation to Mr B and his eating and drin...
For this practice guideline, the original development panel of six members included; a Chief Nursing Officer, Charge Nurse, Clinical Nurse Specialist, Clinical Practice Facilitator, a Professor from a School of Nursing, and an Education Coordinator. The revision panel members included; a Chief of Nursing & Professional Practice, an Assistant Lecturer from York University, a Clinical Nurse Specialist, Clinical Practice Facilitator, a Nursing Professional Development Educator, an Internist/Geriatrici...
Evidence-based practice integrates best current evidence with clinical expertise and patient/family preferences and values for the delivery of optimal health care (qsen.org). Like most medical professions, nursing is a constantly changing field. With new studies being done and as we learn more about different diseases it is crucial for the nurse to continue to learn even after becoming an RN. Using evidence-based practice methods are a great way for nurses and other medical professionals learn new information and to stay up to date on new ways to practice that can be used to better assess
1. What is the difference between a. and a. Which K, S, and A pertain to the care you provided to the patient you have chosen? Why do you need to be a member? K- Describe the limits and boundaries of therapeutic patient-centered care. S- Assess levels of physical and emotional comfort.
The nursing process is one of the most fundamental yet crucial aspects of the nursing profession. It guides patient care in a manner that creates an effective, safe, and health promoting process. The purpose and focus of this assessment paper is to detail the core aspects of the nursing process and creating nursing diagnoses for patients in a formal paper. The nursing process allows nurses to identify a patient’s health status, their current health problems, and also identify any potential health risks the patient may have. The nursing process is a broad assessment tool that can be applied to every patient but results in an individualized care plan tailored to the most important needs of the patient. The nurse can then implement this outcome oriented care plan and then evaluate and modify it to fit the patient’s progress (Taylor, C. R., Lillis, C., LeMone, P., & Lynn, P., 2011). The nursing process prioritizes care, creates safety checks so that essential assessments are not missing, and creates an organized routine, allowing nurses to be both efficient and responsible.
ANA describes “The Scope of Nursing Practice (as) the “who,” “what,” “where,” “when,” “why,” and “how’ (8).’ In other words, it is the responsibility of the nurse to know who their patient is, what the patient’s diagnosis and treatment are, where it is they will be delivering treatment, the rationale behind their actions, and how they will deliver the care. By following the scope of practice, nurses reduce avoidable errors and are aware of the liability their actions entail. The ANA also puts forth a nursing process to guide nurses in treatment. The constantly evolving process is currently assessment, diagnosis, identification of outcomes, planning, implementation, and evaluation (ANA 9). Though this method has dramatically improved nursing care, it may be necessary to repeat steps to adapt to a patient’s changing needs and pathologies. By following guidelines set by the ANA, nurses are able to better connect with their patients and instill the image of professionalism to the public while also optimizing safety
*As my first year in the nursing program comes to a close, I am to write this assessment based upon my abilities in each of the listed outcomes. I know I have much to learn, but I have also gained a tremendous amount of knowledge in the short amount of time I have been a part of this program.
This piece of work will be based on the pre-assessment process that patients go through on arrival to an endoscopy unit in which I was placed in during my second year studying Adult diploma Nursing. I will explore one patient’s holistic needs, identifying the priorities of care that the patient requires; I will then highlight a particular priority and give a rational behind this. During an admission I completed under the supervision of my mentor I was pre-assessing a 37 year old lady who had arrived to the unit for an upper gastrointestinal endoscopy. During the pre-assessment it was important that a holistic assessment is performed as every patient is an individual with unique care needs as the patient outline in this piece of work has learning disabilities it was imperative to identify any barriers with communication (Nursing standards 2006).
The second standard in the nursing process is diagnosis. During this step, the registered nurse analyzes the assessment data to determine the diagnosis or issues (“American Nurses Association,” 2010). Analysis involves recognizing cues, sorting through and organizing or clustering the information, and determining patient strengths and unmet needs. These findings are compared with documented norms...
Evidence-based practice has become a commonly used term in health care in the past few years. It is important for nurses to know what it means, how to use it, and how important it is in protecting patient safety (ONA, n.d). This class has helped me understand nursing research and evidence based practice in a very unique way. Before I joined this program I knew little about nursing research and I didn’t know the importance of evidence-based practice. This class has helped me to understand how to research and incorporate evidence based data into nursing practice. According to Polit and Beck (2014), nursing research is a systematic inquiry designed to develop knowledge about issues of importance to nurses, including nursing practice, nursing education, and nursing administration. Now I’m able to solve complex patient’s problem by using nursing research, analyze data and develop a care plan based on evidence practice.
Evidence-based practice has now become a key phase in nursing and is an issue that requires attention. In the United Kingdom, a recent National Health Service review identifies the need for research to address local clinical practice gaps, which are derived from patients’ needs and perspectives (Department of Health, 1999). Good, robust research is required in order to raise standards of nursing care. Close collaboration between research and practice is vital to the future success of nursing research. Nursing practice is becoming increasingly more evidenced based, it is important that care has its foundations in sound research. It is therefore important that all nurses have the ability to critically appraise research in order to identify what is best practice.
The scientific basis for the health of the public that provides the scientific foundation for the practice of the profession is nursing research. Nursing research includes utilizing numerous philosophical and theory-based approaches as well as various methodologies (American Association of Colleges of Nursing, 2015). Furthermore, nursing research involves identifying and treating symptoms of acute and chronic illnesses as well as the prevention and delaying of the disease process. Nursing research also focuses on deferring the onset of the disease process, disability, slowing the progression and improving clinical settings. Therefore, the influence of research on the practice of the Doctor of Nursing Practice (DNP) is essential for the preparation