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The importance of patient assessment
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The purpose of the paper is to discuss the activities involved during the evaluation of a patient. Evaluation of a patient can be seen as the process of examining a patient critically. It comprises of gathering and analyzing data about a patient and the illness (Allan, 2012). The core reason is to make judgment about the disease one is suffering from. Such judgment will guarantee proper treatment and diagnosis. Typically, gathering of information from the patient is the role of nurses while making judgment and prescription is the doctor’s role (Jacques, 1988). In any case all practitioners are required to know how to evaluate a patient.
Traditionally nurse’s role in evaluating a patient has to record the observations made but not to interpret them. The main observation includes pulse, temperature, rate of respiratory, blood pressure and consciousness level (Alice, 1985). The ability of nurse to record such observations accurately will determine the priority of the patient care. Assessment based on priority setting is one of the major skills that nurses that are newly fit may lack. Th...
J.P., a 58 year old female, presents to the Emergency Room on March 18th. She has a past medical history of cervical cancer, atheroembolism of the left lower extremity, fistula of the vagina, peripheral vascular disease, neuropathy, glaucoma, GERD, depression, hypertension, chronic kidney disease, and sickle cell anemia. She complains of right lower extremity pain accompanied by fatigue, a decreased appetite, increased work of breathing, burning on urination, and decreased urine output for three days.
Corcoran, J., & Walsh, J. (2008). Mental health in social work: a casebook on diagnosis and strengths-based assessment. Boston, MA: Pearson/Allyn and Bacon.
Nurses form an important role in influencing patient safety from everyday tasks and gradually obtaining the patient vital signs have increasingly been seen as a chore instead of collecting clinical evidence. This then creates an extreme danger to patient’s as irregular monitoring of vital signs prevented early detection of deterioration in a patient’s condition, which postpones transfer to intensive care unit ( Kyriacos U et al 2011; Boulanger, 2009). Due to this, a...
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 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 rationale 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 at 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 outlined in this piece of work has learning disabilities it was imperative to identify any barriers to communication (Nursing standards 2006). There were a number of nursing priorities identified, the patient also has hypertension.
Physical assessment can include vitals, medical tests and the nurse’s observation of the patient’s overall health. Luxford (2015) describes physical examination as the collection of measurements and data, which can either be collected through evaluation of each body system or through a head to toe examination. The physical assessment should also be used to note visual observations about the patient’s overall appearance and health status (Luxford 2015). Physical assessment can also include the skills of inspection, palpitation, percussion and auscultation of the patient (Slater 2015). A general assessment is collected during the physical assessment and can include the recording of vital signs, height and weight measurements and observations of overall appearance and mental status (Slater 2015). Slater (2015) discusses how by thorough assessment and collection of baseline measurements the nurse is able to monitor and reassess the patient’s condition. Through the assessment the nurse will be able to see if the body is maintaining homeostasis and can observe physical problems such as mobility issues and skin
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 following essay is a reflective paper on an event that I encountered as a student nurse during my first clinical placement in my first year of study. The event took place in a long term facility. This reflection is about the patient whom I will call Mrs. D. to protect her confidentiality. Throughout this essay I will be using LEARN model of reflection. I have decided to reflect on the event described in this essay since I believe that it highlights the need for nurses to have effective vital signs ‘assessment skills especially when treating older patients with complex medical diagnoses.
Nursing-sensitive indicators are standards and practices used to increase the safety, quality of care, and thus satisfaction of patients. More specifically, these indicators provide nursing staff with the knowledge to identify potential issues and the tools to prevent or reduce the likelihood of negative patient outcomes encountered in the healthcare profession. While these standards of care have been expanded and refined to encompass numerous aspects of nursing, the parallel between nursing quality and positive patient outcomes fuels the continuation of analysis and evaluation of evidence-based intervention and prevention practices. The importance of understanding and evaluating nursing standards, quality of care, safety, and even ethics is
Working in the ICU, in-patient, out-patient, schools, prisons, insurance companies, private homes, among many other settings nurses learn to balance a long list of tasks. In addition to taking care of patients, nurses have an innate ability to be kind, compassionate, work independently, and are customer service pros. Nurses are mediators, hand holders, communicators, weight lifters and order decoders. Juggling patient loads, demands of patient families, corporate bureaucracy and personal life. In other words, nurses are the rock-stars of healthcare.
Hospital data on specific nursing-sensitive indicators could advance quality patient care throughout the hospital because staff would be able to see the prevalence of outcomes and work to prevent negative ones as well as working to set policies in place regarding care of patients related to their diagnosis. For pressure ulcers for instance, if there was hospital data related to which patients are most likely to develop pressure sores/ulcers (like those who are unable to ambulate on their own), care plans could be put in place for interventions such as reposition every 2 hours and as needed, up to chair from bed at least once a day, ambulate as tolerated assisted by staff, etc. Any nurse can delegate these tasks to a CNA or carry them out themselves. For restraint use every hospital has guidelines regarding when it is necessary and how to keep it safe.
This reflection of vital signs will go into discussion about the strengths and weaknesses of each vital sign and the importance of each of them. Vital signs should be assessed many different times such as on admission to a health care facility, before and after something substantial has happened to the patient such as surgery and so forth (ref inter). I learned to assess blood pressure (BP), pulse (P), temperature (T) and respiration (R) and I will reflect and discuss which aspects were more difficult and ways to improve on them. While pulse, respiration and temperature were fairly easy to become skilled at, it was blood pressure which was a bit more difficult to understand.
The Nursing Diagnosis involves “the nurse to identify the patient’s system perceptions and his or her own perceptions, regarding basic structure factors such as: energy, normal temperature, and response pattern as well as degree of potential reaction of the environmental factors that would threaten the stability of the patient system, (Kearney-Nunnery. Chapter 3, pg. 39.) The
The patient needs to be assessed completely by the organization and can not deny any patient in case of emergency. The care given should be continues and it should be holistic. Under the same roof, the patient should get be able to get all kinds of care required. The out come of the care given should be evaluated periodically.
Being able to self assess our health give us the opportunity to change our life style and change the quality of our life style.
The diagnose are carried out based on history which may include the duration of sickness, the characteristics of the sickness and the specific types of food that have been eaten. Some physical exam can also be performed to look for signs and symptoms of dehydrat...