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Critical analysis of patient assessment
Assessment techniques & types in clinical settings
Critical analysis of patient assessment
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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. Based on my assessment, as part of my interdisciplinary team, I would include Mrs. Paul’s primary physician, dietary, physical therapy, and palliative care team. Her physician can prescribe antiemetic medications for the nausea and vomiting, and blood work to determine her metabolic state. The nurse should approach the primary physician and explain her findings and Mrs. Paul’s concerns, signs and symptoms,
T. Paulette Sutton is one of the world’s leading experts in bloodstains and is the former Assistant Director of Forensic Services and Director of Investigations at the University of Tennessee, Memphis. She has been involved in nationally known murder cases and has worked hard during her long career to make a position contribution to the legal system. Sutton says, “Its best for my fellow man that we get the killers off the street.” Since 2006 Sutton has been officially retired but continues to teach, consult, and testify about her area of expertise.
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).
leaves it to her nurse. When the nurse has done all she can to help
Members of the healthcare that should be utilized should be a dietician (because patient eats a lot of canned foods), occupations/physical therapist (help with daily activities and to help with back pain), social worker (to help with services needed for the patient including home care nurse, local support groups, and collaborate with the family to provide optimal care), a home health aide (visit and help the patient). As a nurse, I would also reach out the patient’s primary care physician and explain the patient’s visit to the ER. Informing the primary care
They are to assess, evaluate, share and collaborate patient information to other health professionals to maintain quality and safe care delivery (NMBA, 2010). For example, scenario two illustrates an effective collaboration and communication between the nurse and other health professionals (Scenario 2: Leadership and teamwork in medical emergency teams [Scenario 2], 2012). She made recordings of the patient’s health status, and was able to share her analysis to the leader which enabled him to devise a plan and inform the family immediately. Therefore, effective team work is evident in scenario two. They were able to communicate, trust and respect each other’s opinion in which it provided the most appropriate treatment for the patient (Scenario 2: Leadership and teamwork in medical emergency teams [Scenario 2], 2012). On the other hand, in scenario one, the enrolled nurse failed to evaluate and record her assessment regarding patient’s health (Scenario 1: Leadership and teamwork in medical emergency teams [Scenario1],
There have been multiple indicated reports with Ms. Peterson as the perpetrator for cuts/welts and bruises. Ms. Peterson has utilized excessive corporal punishment i.e. belt when disciplining Anthony. Ms. Peterson was indicated for reports received by SCR on the following dates 9/29/05 (1639217C), 12/1/05 (1639217D), 4/4/06 (1639217F), 4/11/06
nurse becomes the patient advocate letting the physician know the effect of the medication the
The medical secretary, registered nurses, licensed practical nurses, and physicians communicated consistently and appropriately so that all staff could effectively complete the actions required of their respective roles. I noted the strong relationship between the nurses and the physicians. The nurses held a heavy influence on the physician’s decisions regarding a situation, because the nurses were the ones conveying pertinent information related to the patient’s status. Based on the information provided, the physician would make recommendations and provide guidance to the nurses. The physician’s directions were then carried out by the nurse, influencing the nurse’s plan of care for his/her
(AC 1.2, 2.2) The care plan will be supported by team members including professional and non-professional members of staff. Therefore communication is essential to maintain the highest possible level of Jane’s well-being. Members of the team include nurses, GP, doctors, staff from the oncology unit who assist during chemotherapy and non-professionals such as personnel staff (cleaners, staff form reception), care workers, family members. Team members will provide help in different aspects on each stage of her illness. Some of them are to support her family (children: care workers), others to help in everyday life in hospital (care assistant, cleaners). However the nurse is the person who integrate this team and the coordinator during all cancer treatment. Working under supervision provide a nurse with learning opportunities also according to Royal College of Nursing (2002): ‘’Clinical supervision aims to motivate nurses, while being client-centred and focussed on safeguarding standards of client care’’.
Including family members in the care of the patient helps them cope better with the patient’s illness and helps them plan ongoing care when the patient goes home. Gaining both the trust of the patient and family can help the health care team get any details that may have been missed on admission, such as medications the patient takes, or special diet, or spiritual needs. Also, the family may provide pertinent information that the patient may not have divulged to the nurse. Encouraging the patient and family to voice their concerns will help implement a safe plan of action.
Evaluation is the decision making process that involves determining effectiveness of nursing interventions in meeting expected outcomes. Evaluation can be used to decide if the patient or family member understands the drug regimen. Evaluation is also used to evaluate the patients response to therapy. Nurses should check the patient’s or family’s understanding of the drug regimen noting if one or both seem to understand the presented material.
First and foremost, an individual nurse should consider social determinants in the treatment by asking the right questions about patients’ nutritional habits. A nurse should be able to determine whether patients are able to make healthy living decisions. If not, as professionals, they should offer patients information how to get access to nutritional food by working within their financial means.
I would also have to explain to the informant that their information will have to be passed on in confidence, in order for Linda to receive some help. The information would be shared with the multi-disciplinary team, which in respite care could include the family doctor, public health nurse, social worker and clinical psychologist. They would discuss the best possible ways in which to approach and treat Linda’s problems involving her family and also liaising with her school.
There are many members of the inter-professional team, all of which are contributing to the healthcare of acute and critically ill patients. Every member of the team has had education and obtained a license of practice compatible to their level of knowledge (Prater, Fundamentals of Nursing, 2013). As a practical nurse you need to be mindful of your scope of practice in relation to registered nurses, certified nurses’ assistants and other healthcare professionals. With so many different people involved in the immediate care of a patient, there is always the possibility of a mix up. The purpose of this paper is to help differentiate between the roles of the healthcare staff, which will in turn help develop a knowledge base for prioritizing care;
After the handover, I was asked by my mentor to attend to a patient who is bed ridden to have her personal care done with the assistance of one of the health care assistant staff. The patient was recently admitted to the ward and she looks sc...