Holistic Assessment of a Patient in a Clinical Setting Essay

The author read Mrs. X’s medical notes prior to their initial consultation to afford herself the knowledge she required should she need to prescribe for her when fully qualified. It was evident from reading her medical notes that there were a few considerations to take note of before commencing any treatment, such as her medical history, drug history and allergies. Her past medical history consisted of Type 2 diabetes mellitus, which was diet controlled, hypertension, hypercholesterolaemia, neuropathy, rheumatoid arthritis and raynauds syndrome.

The assessment process is the back bone to any package of care and it is vital that it is personal and appropriate to the individual concerned. Although studies have found that there is no singular theory or understanding as to what the purpose of assessment is, there are different approaches and forms of assessment carried out in health and social care. These different approaches can sometimes result in different outcomes.

Nursing process is a systematic process that involves a continuous cycle of five interrelated phases: holistic assessment of a client, nursing diagnoses, nursing care planning, implementation, and evaluation (Wilkinson et al. 2015). It enables nurses to assess the person’s health status and health care needs, to create plans to meet the identified needs, and to provide and evaluate individualised nursing interventions according to the person’s needs (Luxford 2015). The holistic assessment is the first step of the nursing process that includes the collection of subjective and objective data related to the physical, psychological, social, developmental, cultural, and spiritual status of a client (Wilkinson et al. 2015). This comprehensive approach to nursing assessment is essential because it allows nurses to comprehend not only clients’ health status, but also their routines and needs in order to incorporate their life-styles into the care interventions (Luxford 2015). It ultimately enables nurses to provide appropriate quality person-centred care rather than nurse-initiated care (Luxford 2015). Responsibility for holistic nursing assessment is supported by the Registered nurse standards for practice (2016), ‘Standard 4.1: The registered nurse conducts assessments that are holistic as well as culturally appropriate’ (Nursing and Midwifery Board of Australia [NMBA] 2016, p. 4). This essay will discuss the elements and the importance of holistic assessment in nursing.

Throughout the duration of my placement is was crucial that there was a safe quality of care being given to the residents. This overall achieving the goal for the residents, which is to maintain or attain the highest possible health and wellness through both short term and long term realistic expected outcomes (Lewis 2010 p.17). During my placement, it was important to set measurable and realistic short term goals for residents for a range of different reasons. These included tasks such as breathing exercises and eating 3 main meals each day. The specific task would be included in the residents’ care plan to ensure all staff members were aware and could document any concerns or changes.

I am currently studying HNC Health Care and as part of my course I have to complete a graded unit, this will entail three stages; Planning, development and evaluation. This will be carried out while on placement within a hospital setting, within the planning stage I have to choose a patient and assist them with a nursing activity. I have chosen to follow Roper Logan and Tierney twelve activities of daily living the reason for this is that I find it to be the nursing model that is most effective as each activity has its own importance to the survival of life; also it follows the objectives of my graded unit. I have chosen the AL of eating and drinking as the patient I have chosen has severe Rheumatoid arthritis and has lost the use of her

A Critical Analysis of Patient Centred Assessment Including a Reflective Analysis of a Simulated Problem-Focused Assessment

Orem’s Self-Care Model (2001) was developed by the American nurse Dorethea Orem and is very person centred by concentrating on what the patient is able to do independently and focussing care around that aspect (Barratt, Wilson and Wollands, 2012). However, it has been criticised for the use of complex language, terminology and concepts (Murphy, Williams and Pridmore, 2010). RLT was used in this case due to Susan’s main concern of shortness of breath (SOB) affecting all her AL and is the sole model used on the admitting ward and local NHS trust admittance paperwork.

As a woman, the narrator must be protected and controlled and kept away from harm. This seemed to be the natural mindset in the 19th century, that women need to have guidance in what they do, what decisions they make, and what they say. John calls her a “little goose”(95) and his “little girl”(236), referring her to a child, someone who needs special attention and control. His need for control over her is proven when she admits that her husband is “careful and loving and hardly lets me stir without special direction”(49). John has mentally restrained the speaker’s mind, she is forced to hide her anxieties, fears and be submissive, to preserve the happiness of their marriage. When the narrator attempts to speak up, she is bogged down and made guilty of her actions. Her husband makes her feel guilty for asking, he says, “‘I beg of you, for my sake and for our child’s sake, as well as your own, that you will never for one instant let that idea enter your mind!’”(225-226). By making her feel guilty for her illness, John has trapped her mentally from speaking up about it, convincing her that she must be more careful about her actions. Men often impose the hardships placed upon women during this era. They are often the people reassuring them of their “womanly” duties, and guiding them

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

In the first step of the Tanner (2006) model nurses use their personal knowledge and experience to notice whether the patient requires attentions based on their expectations and looking at environment of the patient. Therefore, for an experience nurse it is easier for them responding to the similar situation if she or he revisit because the knowledge is already there through experience. In the case of Mr Devi, assessment will perform using systematic assessment based on the ABCDE approach (Airway, Breathing, circulation, Disability and Exposure). The ABCDE approach is an evidence-based practice widely accepted and used by all the members of a multidisciplinary team (MDT) to assess an acutely ill patient (Harrison and Daly 2011). First, life-threatening

This assignment is a case study of a patient who was admitted to a respiratory ward with acute exacerbation of asthma. This assignment will discuss nursing an adult patient with asthma, also it will aim to critically assess, plan, implement and evaluate the patients nursing needs using the Roper, Logan and Tierney nursing model (1980). This case study will focus on the maintaining a safe environment. It is worth noting that the activities of daily living are interlinked e.g. according to Roper et al (1980) breathing is an activity that is crucial for life therefore all other activities are dependent on us being able to breathe. The nursing management, pharmacological agents and the tools used will be critically

Holistic nursing to me is a practice of applying both subjective and objective patient assessment into the plan of care. Not only do we need to look at the physical condition of the patient, but also their social and environmental factors that influence their state of health. When this application process is incorporated into the patient plan of care, we are incorporating all aspects of the patient’s life that help define and create their ideal state of health. In review of several nursing theories discussed by Montgomery-Dossey and Keegan (2012), which incorporate the aspect of holistic nursing practice, I found that Jean Watson’s Theory of Transpersonal Caring was most closely linked to aspects of my current nursing practice.

Holistic assessments in nursing provide a unique quality of care to the individual patient. Holism in the provision of care includes assessments obtaining data about the physiological, psychological, sociological, spiritual, developmental, cultural and environmental aspects. It is imperative that the nurse conducting these assessments adopts methods in the nursing process that reflects the standards outlined in Australian Nursing and Midwifery Council National Competency Standards for the Registered Nurse to ensure the health and wellbeing of the patient is maximized and maintained throughout the time health care is received. Nursing processes are directed at restoring overall harmony for the patient therefore an understanding of the

The first stage of the process is assessment. Roper et al (2001) refer to this process as ‘assessing’ indicating an ongoing activity; this encourages nurses to recognise the on-going nature of this initial phase. The assessing stage includes gathering information about a patient, reviewing this information, identifying actual and potential problems and prioritising (Roper et al 2001). Roper et al (2001) explain the importance for assessing, as early as possible in the patient’s stay. Extensive, in-depth information may not be gathered on an initial assessment, however any information obtained contributes towards individualised care (Roper et al 2001). Ambrose and Wittig (1998) explain that the initial assessment becomes a foundation for ongoing assessing and holistic care. Barrett, Wilson and Woollands (2009) concord with Roper et al and Wittig in that assessing is an ongoing process and elaborate on this explaining that assessment should not be confused with admission. They state “an admission tends to be a one-off process when you first meet the patient, whereas assessment carries on throughout your relationship with the patient” (pg22). Assessment enables the nurse and patient to identify actual and potential problems. Although, some problems can be directly related to biological needs, holistic needs must be considered, i.e. psychological state and cultural/social standing

Nursing informatics, health informatics, and clinical informatics all differ in assisting the development, management, and improvement of Healthcare. With out the support from different sections in health industry, the technology and data would not stay up to date and cost efficient.