Nursing Essay: Patient Assessment

This was my first shift back from having a few days off and I returned to work on a night shift. Patient A was admitted to the hospice that day. She was admitted for general deterioration and she had tried to maintain her independence up until breaking point. It was handed over she has aphasia.

The aim of this assignment is to critically discuss the nursing assessment individualised care and nursing interventions of the acutely ill patient. The patient discussed developed severe sepsis due to a urinary tract infection and her condition deteriorated during the recovery process in the nurse’s care. Lovick (2009) defines sepsis ‘as a known or suspected infection accompanied by evidence of two or more of the SIRS criteria’. SIRS is outlined as a ‘systemic inflammatory response’ consisting of two or more of the following symptoms ‘temperature >38 degrees Celsius or 90 beats per minute, respiratory rates greater than 20 breaths per minute and white blood count higher than 12,000 cells per microliter or lower than 4000 cells per

I think the feedbacks that I have received were really useful and will certainly help me with my future personal and professional development. I feel that the given feedback has pointed out my weakness and that point that I need to work on for the future. It has motivated me to join in group deciosituon and to express my ideas. I feel much confidence when talking to others especially in group discussions. I understand that nursing is a profession that requires you to be more confidence with communication as you have to work with lots of different people from all sorts of different backgrounds and therefore, practicing these skills will become handy for the future.

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

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

The aim of this essay is to demonstrate the assessment process of a patient using the Roper Logan and Tierney (RLT) model of nursing framework and to show how the nursing process works alongside this model. This will be shown by a holistic history of the patient being shown, followed by how the RLT model is applicable to this patient. This is then followed by one nursing intervention being discussed showing how the nursing process is applied to patient care. The patient will be referred to as Mr Frederick Valentine to protect the patient’s anonymity as stated in the Nursing and Midwifery Council Code of Conduct (2008) guidelines.

The national league for nurses defines critical thinking in the nursing process as “a discipline specific, reflective reasoning process that guides a nurse in generating, implementing, and evaluating approaches for dealing with client care and professional concerns” (Kozier, 2008). This definition is imperative to help a nursing student learn how to think in terms of nursing care. Nursing students must achieve a comprehensive understanding of critical thinking in order to understand the nursing process. The purpose for this paper is for nursing students to learn how to use the nursing process, how to properly document their findings and assessments, and correctly implement APA formatting in a formal paper.

Lily was a 65 year old lady with stage 5 CKD, she had recently begun hemodialysis treatment three times a week as an inpatient and had been responding well to treatment. During dialysis treatment on the morning of the first day, Lily’s observations showed that she was: tachycardic, hypotensive, tachypnoeaic, had an oxygen saturation level of 88% and was becoming confused and drowsy. It became apparent that Lily had become hypovolaemic. The hypovolaemic shock seen in this patient was of a particular critical nature due to the fact that her dialysis treatment had moved her rapidly through the first two stages of shock with her compensatory mechanisms failing very quickly (Tait, 2012). It was also much harder to identify the early signs of

Starting the Registered Nurse (RN) to Bachelorette of Science in Nursing (BSN) program at Jacksonville University in June 2015 was a simple transition for me. I had graduated an Associates Degree in Nursing (ADN) program in December 2014 and became a licensed RN in January 2015. I had just gotten hired for my first nursing position the month prior to the start of class and had not yet started working. I was very much still in student mode. While this makes it a bit easier to learn and process information in a classroom setting, I had no real world experience to help guide me. Through the knowledge I have gained as a student at Jacksonville University I have become a competent and well-rounded nurse. I am able to quickly problem solve and utilize critical thinking to identify and rectify issues. I have even put together, and will be presenting, and presentation about nursing practice for staff members at the facility where I work.

“Advanced nursing practice is the deliberative diagnosis and treatment of a full range of human responses to actual or potential health problems.” (Calkin, 1984). Advanced nurse practitioners attempt to maximize the use of knowledge and skills and improve the delivery of nursing and health care services. The field of advanced nursing practice differs from basic practice as the former requires clinical specialization at the master’s level. At this level, nurses become expert practitioners whose work includes direct and indirect patient care. Direct patient care involves caring for patients and their families; this is the focus of my section on nurse clinicians. Indirect patient care includes work as an educator, researcher, and a

The purpose of this paper is to provide a synopsis of the importance of assessment and diagnosis in the counseling process. In the first two sections, the roles of assessment and diagnosis as they relate to case conceptualization and treatment planning will be explored. The potential implications of misdiagnosis will be the focus of the final section.

Nurses provide excellent patient care, teach patients about health conditions, and give advice and support to patients and their families. Nurses have a variety of duties. They must monitor and record patient symptoms, take vital signs, watch patients diet and physical activity, supervise less skilled nurses, and order and interpret tests to access the condition of the patient. Nursing can be a wonderful, caring, and thoughtful job. However, to other nurses: nursing can be a difficult, tiring, and stressful job. Any job can be tough but nursing is emotionally and physically draining on a person. Nursing can be such a burdensome and demanding job sometimes because of the long hours, the exam to become a nurse, and dealing with other people.

When the patient first came in I think I did quite well as I welcomed

This report will discuss the health assessment of a client who presented to my PEP facility, Clinic 275. Clinic 275 is a confidential and complimentary walk-in sexual health service which provides medical consultation/advice, testing and treatment for sexually transmitted infections (STIs) (SA Health 2016a). Ultimately, this paper will illustrate how an ongoing health assessment, history taking, provision of client education and care options of certain STIs are fundamental to guiding the planning, implementation and evaluation of care for specific people. All information regarding the client, who will be referred to as R, was permitted for use by the facility and will maintain confidentiality in accordance with the guidelines of the Government of South Australia (2015, p.7; Nursing and Midwifery Board of Australia 2016).

Today I had a great day at the clinic. For the morning section, I had Omar Lora as my patient. Last time when he came, I collected all my assessment data. Today I updated his medical history, dental history, vitals, and EIOE, then I completed filling out the gingival assessment, the treatment plan, and the SAOP. Finally, I was ready to have my assessment data checked. It went really well, and I learned ways to helped me be more efficient with my time management, for example, I did not know how to have my radiographs up in the other monitor while I was doing my assessments. It was a little time consuming having to open and minimized the window every time I needed to look at the radiographs. Also, I discovered that having a piece of paper out and taking