Comprehensive Health Assessment

By carrying out an assessment nurses can identify the causes of problems that require medical involvement. Nettina (2006)

Comprehensive assessments is the most valuable piece which allows Nurse Practitioners to know about the health risks, strengths and needs of their patients. Furthermore, the comprehensive assessment strengths the relationship between the Nurse Practitioners and their patients. From clinician-patients relationship, it helps a complete assessment to answer patients questions which in the long run help to achieve measurable goals and provide quality outcomes to the patients. Nurse Practitioners use comprehensive assessment approach to analyze, interpret, implement and follow up care to ensure their patients receive appropriate care and prevent inappropriate diagnosis. Comprehensive assessment is where the patients are encourage to

I was able to gather a lot of information on my patient when I was taking his health history, giving his shift assessment, and reviewing his charts. I used this step to offer effective nursing care to determine the priorities of what is the most important issue for which the patient should be treated.

The health of a family is a vital part of how that family interacts with one another and how each individual of the family will function in society, later teaching their children about a healthy lifestyle or lack thereof. The family health assessment helps to identify risk factors and potential dysfunction (Edelman, 2014) I interviewed a single parent family home about their health and how they perceive it. This family is an all-male family, an athletic seventeen year old boy getting ready for his senior year, a twenty year old young man, and a hardworking, dedicated, overweight father.

The purpose of this paper is to conduct an in depth exploration of the nursing care considerations of patients in a specific clinical area. Through the synthesis of prior knowledge, clinical experiences and skills, evidence based best practices, and care of patients a comprehensive care and teaching plan will be composed. Integration of critical thinking and clinical reasoning skills, combined with evidence-based research will provide confirmation of nursing process comprehension. The inclusion of reviewed literature will further support knowledge and understanding.

Clinical reasoning is embedded in nurses’ thinking for patient care (Levett-Jones 2013). It is a spiral, continuous mental process, underpinned by critical thinking theory and a sound body of nursing knowledge (Levett-Jones 2013). The clinical reasoning cycle includes considering patient’s situation, collecting cues, processing information, identifying problems, establishing goals, taking action, evaluating outcomes and reflecting on the process undertaken (Levett-Jones 2013). Nursing practice for registered nurses is guided both by the National Competency Standard (Nursing and Midwifery Board of Australia 2006) and the Nursing Practice Decision Flowchart (Nursing and Midwifery Board of Australia 2010) to ensure patients’ safety and to optimise care by challenging medical assumptions and facilitating evidence-based practice. The clinical reasoning framework, therefore, allows nurses to prioritise the most time sensitive and specific information, to recognise deteriorating patients and to manage complex clinical situations (Levett-Jones & Bourgeois 2011). This paper will focus on processing information and identifying the two major problems in the case study of Mr. Brown, a 74-year-old man, who was admitted to hospital after a ‘fainting’ episode with chief complaint of dizziness.

Over the past 30 years nursing has evolved from a task-oriented to a logical and systematic approach to care, using theories and models to guide practice. According to Jasper (2007, p117) theories of decision making in medicine tend to favour logical, precise analytical models which are held to be testable, unambiguous and repeatable, therefore satisfying scientific principles. These represent important ideas of certainty and rationality that are intended to provide a sense of security and reliability. When used correctly a nursing model should give direction to nurses working in a particular area, as it should help them understand more fully the logic behind their actions. It should also act as a guide in decision-making and so reduce conflict within the team of nurses as a whole. This in turn should lead to continuity and consistency of the nursing care received by patients according to Pearson et al (1999,p ).

A comprehensive family assessment provides a foundation to promote family health (Edelman & Mandle, 2011). 1987 Marjorie Gordon purposed 11 functional health patterns to use for guidance in order to facilitate nurses to have a frame work for the family assessment in. Gordon’s 11 functional health patterns help organizes basic family assessment information. This standardized format will guide nurses to complete the family assessment using system approaches, which will identify a patient’s

A community health assessment is a fundamental instrument of public health practice. Its objective is to depict the health of the community, by presenting information on health standing, community health needs, resources, and epidemiologic and other studies of present local health problems. It seeks to recognize target populations that may be at augmented risk of poor health results and to increase a better understanding of their needs, as well as evaluates the larger community surroundings and how it relate to the health of people. It also identifies those areas where better information is desired, particularly information on health differences amid different subpopulations, quality of health care, and the incidence and severity of disabilities in the population. The Community Health Assessment is the foundation for all local public health development, giving the local health component the instance to recognize and network with key community leaders, businesses and concerned residents about health priorities and concerns. This information shapes the foundation of improving the health status of the community by way of a strategic plan (The Municipal Public Health Services Plan Community Health Assessment Guidance and Format, n.d.).

A family consists of a group of interacting individuals related by blood, marriage, cohabitation, or adoption who interdependently perform relevant functions by fulfilling expected roles. (Edelman, Kudzma, & Mandle, 2014, p. 150)

Using Gordon’s functional health patterns to assess a family will guide the nurse in developing a comprehensive nursing assessment that is holistic in nature. Gordon’s functional health patterns are founded on 11 principles that are incorporated within the nursing practice. These 11 principles serve as a framework for a thorough nursing assessment in which to build a holistic and individual family care plan (Grand Canyon University, 2011). The author has developed family-focused questions for each of the 11 principles and utilized these questions as a tool to assess her own family. This paper will summarize the family assessment that was performed by the author and discuss two wellness nursing diagnoses that

The development of the nurse’s ability to clinically reason and take appropriate and timely action can, in time, become an instinctive and automatic process. Reflective practice by the nursing professional will highlight the areas in which further improvement is needed. Essentially, it is the responsibility of the individual nurse to identify the need to develop this ability, and the skill to effectively communicate the patient’s condition to the other members of the healthcare team to produce positive patient outcomes.

The third standard of practice is outcomes identification. During this phase, the registered nurse identifies expected outcomes for a plan individualized to the patient or the situation (“American Nurses Association,” 2010). During this step outcomes must be derived from the nursing diagnosis and must be measurable, realistic and attainable by the patient. The registered nurse involves the patient, family, heath care providers, and others in formulating expected outcomes when possible and appropriate. The registered nurse must also consider associated risks, benefits, costs, current scientific evidence, expected trajectory of the condition, and clinical expertise when formulating outcomes (“American Nurses Association,” 2010). Example of an

Throughout this complete health assessment, I will approach my patient, a 49 years old, female, married patient, and perform a head to toe examination. Starting with the gathering of information, I will start with biographic data, reason for seeking care, present illness, past health history, family history, functional assessment, perception of health, head to toe examination, and baseline measurements. The subjective data will be collected first, where the patient will provide necessary information about every organ system for further examination while the objective data will be amassed in every system based on my findings. This assignment serves as an opportunity to establish a nurse-client interpersonal relationship that

Essex County is located in the North eastern part of new jersey. The history of Essex county dates back to 1666 when 30 families from Connecticut established settlement along the banks of Passaic river. Essex County was officially established in 1682 by east jersey legislature. Essex County is 129.631 square miles. The Geopolitical communities are designed by natural or human made boundaries (Maurer and Smith, 2009). It holds community safer for the residents and the governing body.