Introduction . I Have Been Asked To Do An Assessment On

The next stage is to implement the care package, ensuring all the care staffs involved are made aware of the individuals’ needs and preferences. After 6 weeks we would then review the care package, making any adjustments if required, and following that the care package would be reviewed again in 12 months. If for any reason there was a change to the individuals needs or situation then a review would be carried out at an earlier date in order to address the change.

initial step of assessment. I find it important to read patient’s biographical details, medical history, social background and their health progress by then inviting 10 of my clients. Within the community ,who has respiratory illness such as asthma suffering from exacerbation of symptoms of shortness of breath.

As a Registered Nurse is a crucial component to ensure that there is effective communication between the nurse and patient. As well as being respectful to the person’s dignity, culture, values, beliefs and rights. This is because everyone is different, and due to this it is important that I am being cautious to each person’s individual needs.

During an initial assessment an individual’s ability and communication methods are established. This is done when an individual arrives into care. Everyone involved in the care of this service user is made aware of their needs and preferences regarding communication and any changes are recognised during reviews and shared with the team to ensure the individual’s needs are met.

The second step that I used in the nursing process was diagnosing. Based on my results from my assessment, I was able to use that information to come up with a couple nursing diagnoses. This step is used to offer effective nursing care because it helps me set an intervention and plan of care to help my patient’s health outcomes for the better.

Physical Examination: General: The patient is an alert, oriented male appearing his stated age. He appears to be in moderate distress. Vital signs: blood pressure 132/78 and pulse 68 and regular. Temperature is 38.56 oC (101.4 oF). HEENT:Normocephalic, atraumatic. Pupils were equal, round, and reactive to light. Ears are clear. Throat is normal. Neck: The neck is supple with no carotid bruits. Lungs: The lungs are clear to auscultation and percussion. Heart: Regular rate and rhythm. Abdomen:Bowel sounds are normal. There is rebound tenderness with maximal discomfort on palpation in the right lower quadrant. Extremities: No clubbing, cyanosis, or edema.

Care plans are developed by the service users, and when needed with help and assistance from friends and family. These plans are then to be agreed by a social worker or senior care manager e.g. the nurse or senior care worker depending on if the person is nursing or a residential client. The planning system allows the individual’s to:

Assessment tools are used in the care planning process to build up a holistic picture of an individual’s needs. When all the details have been recorded an assessment can be made and suitable care and support can be identified. A few of the assessment tools are information from the individual such as diaries, observations, medical histories and checklists.

Using patient centred care during this process will ensure that the care and treatment is specific to the patients’ needs and choices, (NICE, 2013) maintaining and ensuring dignity at all times. This focuses on three important features – respect, compassion and sensitivity, (Royal College of Nursing (RCN), 2014) aiding the therapeutic relationship, (Cobb et al, 2012) which in turn will provide better care for the patient as they begin to

In this Assessment nursing course, one of the major things that is taught is the most important part of giving proper care to a patient. Correct patient assessment is needed before any nursing care plan or treatment can be implemented. This post-review of a person’s assessment will demonstrate the proper way to go about assessing a person’s health.

Assessment in the nursing process will establish the patients' ongoing needs and provide a quality of care best suited to the individual, to achieve a desirable health outcome.

This assignment will investigate a needs orientated approach to care, critically discussing the nursing process. It aims to show an understanding of what a nursing model and the nursing process is, looking in detail at the relationship between this nursing process and the Roper, Logan and Tierney (RLT) model of nursing. This essay will explore how the nursing model and process is implemented in practice, considering how the RLT model assists nurses to adapt a problem-solving technique when developing care plans for individuals. Strengths and limitations of the RLT model and the nursing process, in relation to developing care plans, will be critiqued along with the effectiveness of

Despite the problems with reliability and verification, the available Chinese records and accounts offer the best glimpse into the land and people of Wa.

In other words, it can defined also as the series of questions the clinician ask to the client about each organ system or the body part during the first interview (history) and the physical examination to reach to the most appropriate findings about the client’s medical history and presenting illness. Example of the questions: the examiner can determine the history of fatigue, travel to other countries or the environment, any change in the lifestyles, any signs of fever or weight change. Moreover, the clinician can ask about the patient’s family; who live with the patient?, what is the patient’s relation with whom who s/he lives with?, and is s/he happy in his/her family?. Also can ask the patient about his/her hobbies and interest, does s/he have pets, does s/he exercise daily? And so

After, assessments and interventions I would evaluate patients outcome. When caring for a patient I frequently communicate to patient, physician, and charge nurse about patient’s change in condition.