When the patient such as Annie is admitted in to the health facility/ hospital, a complete assessment is required to determine both present and future needs and complications that can arise. This is done through examining both health history and physical assessments. Identifying a patient’s health history is achieved through implementing Gordon’s Functional Patterns ‘provides a functional framework for nurses to collect a range of information that can deduce between both dysfunctional and functional behaviour’ (Berman, Kozier & Erb, 2011). Physical assessment data is obtained through using a systematic approach, which involves using a head to toe assessment. The purpose of this type of assessment is the fact that it allows nurses as according to (Berman, Kozier & Erb, 2011) to ‘supplement, confirm or …show more content…
This method would be appropriate when dealing with Annie as it allows for a comprehensive approach to be taken, however it must be noted that not all steps apply to this patient as some are irrelevant to the case at hand. The sections involve looking into health perception and health management; this sees data collection, which is focused on Annie’s level of health, well being, and also practices for maintaining health, for this patient this involves medical officers prognosis of gout. Which is causing her pain in her right toe, which is leading to decline in her mobility and also a change in her sleeping pattern as she has been deprived of a two nights of sleep. From this information it can be determined that a walking aid such as a walking stick is need so that she can bare the weight on her left hand side, also the Annie should be placed close to toilet amenities to reduce her from walking to far to reduce
At the multidisciplinary meeting, the nurse will collect and assess the information provided by the other disciplines and family members stating that the patient is not at her prior level of functioning and then analyze the information to develop a diagnosis of deconditioning. Next, the nurse identifies outcomes for the patient to get stronger, achieve prior level of function, have activities of daily living (ADL’s) met in a safe environment by planning for home health, equipment, and 24/7 supervision through family or placement in a facility. This will be implemented by coordinating delivery of a walker and a 3 in 1 chair prior to discharge to daughter’s home with the home health agency nurse, physical therapist, and aide scheduled to start that day. In a week, the nurse evaluates that outcomes are being met by following up with patient, daughter, and home health agency evaluating that the patient is getting stronger, ADL’s are being met, and will soon be able to return to living independently. To achieve these standards of practice, every nurse should be aware of her own nurse practice act to ensure to be functioning with in the laws of the nurse’s state and to ensure the best outcomes and safety of the patients. In closing, it is every nurses duty to be the best nurse they are capable of being by looking at the scope of nursing practice which gives us the framework to achieve
Upon admission to the ward holistic assessment would be performed. Lucy would be assessed according to 12 activities of living (AL), mentioned in Roper, Logan and Tierney model. This holistic approach enables to develop a care plan that will identify the problems for Lucy in performing certain activities, whilst allowing her to remain independent with other activities.
The nurse would firstly identify if Mrs Jones is at risk of falls by conducting a falls risk assessment using an evaluation tool such as the Peninsula Health Falls Risk Assessment Tool (FRAT) (ACSQHC, 2009). The falls risk assessment enables the nurse to identify any factors that may increase the risk of falls (ACSQHC, 2009). The falls risk assessment tool focuses on areas such as recent falls and past history of falls; psychological status for example, depression and anxiety; cognitive status; medications including diuretics, anti-hypertensives, anti-depressants, sedatives, anti-Parkinson’s and hypnotics; as well as taking into account any problems in relation to vision, mobility, behaviours, environment, nutrition, continence and activities
The nurse needs to describe what focused health assessments they think would best suit the patient. The nurse needs to work out a way in which we can help decrease Alice’s heart rate and blood pressure. To do this the nurse would perform a neurological assessment and a head to toe assessment. These two assessments will give the nurse more information about Alice’s nervous system, if she is in any pain and what further assessments and treatment need to be completed. A neurological assessment is a technique of gaining specific data in relation to the role of a patient’s nervous system (Ruben Restrepo).
Bostock-Cox (2013)) maintains that the 6 C’s of nursing are firmly embedded in emotional intelligence, (Rankin 2013) an essential quality required by nurses to effectively relate to their clients and colleagues. The 6cs consists of care, compassion, competence, courage, communication and commitment. Care is the vital aspect in nursing which involves nurturing or looking after patient’s wellbeing and welfare to impact on their individual life and care. In regards to Edna, it could be said that the most relevant quality of care, competence, compassion and communication are needed to motivate, uplift her spirit and encourage her. In Edna’s case, the community nurse would also need to think about some other issues that may arise such as maximizing her independent or her capability to think for herself, her social isolation, mobility, adequate nutrition, fluid intake and as well as treating/dressing her leg ulcer to avoid infections.
Morgan read over each patient assessment in their chart, as well as rounding on each patient daily to gather her own assessment. With all of the data, she came up with diagnosis that was required from her. Morgan stated the nursing diagnosis she most frequently uses is risk for falls. Goals are then set depending on individual needs. By collaborating with the interdisciplinary team in a therapeutic way, interventions are implemented to meet each patient’s needs. Evaluations are performed daily by case managers through interdisciplinary rounding and the goals that were made are assessed and any changed to the plan of care are made. Case managers will follow up with outside facilities that patients transfer to after a hospital admission to evaluate their progress. If a patient is readmitted to the hospital within 30 days of discharge, a reevaluation is
In the first phase of the nursing process is assessment, which consists of data collection by means as questioning, physical examination, observation, measuring and testing (Stedman's Medical Dictionary , 2006). Performing a full body assessment and take vital signs which will be used as a baseline to compare and contrast during the patient hospitalized period. Assessing is efficient, continuous; require validation and communication of patient data.The assessment phase...
Thirteen years of working as a nurse in the UK has provided the author a vast experience in her speciality. Included in this practice was eight years of working before in High dependency
Upon evaluation of Mrs. Paul, I would do a subjective and objective assessment. I would first ask Mrs. Paul about her history and what signs and symptoms she is encountering at the present time. I would then do a physical assessment of Mrs. Paul, and include questions about her signs and symptoms of fatigue, weight loss, nausea, and vomiting.
As nurses and future NPs, we have to look at a patient in a holistic manner. If the patient shows signs and symptoms pertinent to only one body system, you would not just look at that particular system. Rather you would conduct a head-to-toe assessment to rule out or rule in other diseases and do a more thorough examination on the system that the patient has specific complaints about.
As I moved through each of the case studies, I was able to expand my knowledge and learning regarding the clinical decision making process. In particular, I believe my understanding as to the importance of conducting a physical assessment of a patient was the largest development I had in my learning. This is due to the fact that as the course went on, it was reinforced to me that a physical assessment is imperative to care as it allows the nurse to determine any health concerns that a patient may have, whether they are associated with his or her initial reason for the appointment, or separate. Following this assessment, the nurse can then work with the patient to establish a specific care plan that can meet his or her needs and goals. Moreover,
middle of paper ... ... The priority for this patient was to establish that she was fully aware of what the procedure involved and the possible risks and complications. I feel that the pre-assessment form used within the unit is far too fundamental, if elements of the roper et al activities of daily living were to be incorporated this would help in achieving a much more in-depth holistic nursing assessment enabling for the best quality and level of care to be given to all patients arriving in the unit. Whilst I feel a full nursing assessment is not fully necessary for a day case unit, as previously stated I feel that the communication element is an excellent way of ensuring a better holistic approach is achieved, it will also help to achieve better documentation and communication between all staff members.
"A Guide to Taking a Patient's History” is an article published in an August 24th, 2007 issue of Nursing Standard. Written by H. Lloyd and S. Craig, the process of taking a history from a patient is outlined. Many aspects pertinent to obtaining a sufficient health history are discussed. In addition to providing a framework for completing a thorough health history, guidelines and interview techniques are explored.
(Bickley, 2017, pg. 78). This critique assures that the practitioner has addressed any emotional clues. The practitioner when clarifying the patient’s perspective can do another critique of effectiveness. When the patient present with a symptom there characteristic words the practitioner can use for clarification. These characteristics are “onset, location, duration, character, aggravating/alleviating, radiation and timing” (Bickley, 2017, pg. 79). This critique addresses the accuracy of the history. Through motivational interviewing, the effectiveness of the health history is able to account for adherence. The advanced practiced nurse “engages the patient to express the pros and cons of given behaviors” (Bickely, 2017, pg. 81). The ability to analyze the health history consistently provides the practitioner the opportunity to examine the findings and its relevance to the patient’s care. A critique is a clear evaluation of the health history assessment. As the interviewing process closes, assurance for final questions by the patient answered.
Caring for an individual requires unceasing monitoring of their health, which includes vital signs, their environment, their loved ones, and more aspects of their everyday life. My patients’ health status reflects the continuous change in their life, and if I am able to properly care for them as their nurse, there may not be large fluctuations in their health status. I will be able to help them stabilize their unique pattern so that they can resume their lifestyle as best as they are able