Nursing Head To Toe Assessment

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.

Hi Terry. Nice initial post and I enjoyed reading it. I learned to gather my data accurately and perform the head-to-toe assessment thoroughly. The data that we gather during assessment should be factual and complete to provide diagnostic reasoning, decisions, and proper treatments for patients (Jarvis, 2012). I definitely agree with you, the Shadow Health Assessment with Ms. Tina Jones was also my biggest moment from this course. She was surely challenging, but I would say it was worth it. The comprehensive assessment was difficult and I spent hours in order for me to complete the assignment. I enjoyed doing the assessments of each system. I learned the importance of documenting accurately, clearly, and concisely. In addition to that, the

I am pleased to state that I have been a registered nurse for forty years. At this moment, I continue working in nursing while pursuing my Bachelor of Science in Nursing degree. My intended month of completion is October 2012. My experience in nursing education has motivated me to continue my education and pursue a Masters degree in a nursing related field commencing in 2013. Thus, in terms of my career planning, my education is a crucial part to my professional development. Extending and deepening one's education, especially within the career field of one's choice, can only bring upon additional professional opportunities as well as opportunities for personal growth. My career planning includes building upon my decades of experience in obstetrics, my particular area of specialty, expertise, and passion, with the assistance and addition of higher education. I believe in terms of career planning, my strengths include foresight, preparation, internal motivation, and focus.

The knowledge of nursing sensitive indicator can be helpful in providing the patient care which meets the quality and ethical standards. Nursing sensitive indicators rely on evidence to take patient care decisions (Patrician, 2010). According to Patrician (2010), Evidence Based Nursing is the use of personal expertise and research to take decisions on patient care. In case of Mr. J, there is a clear lack of evidence based nursing. Mr. J was kept in restraint without considering that Mr. J was not trying to get out of bed by himself. When the pressure ulcer was identified, the nurse

Nursing sensitive indicators reflect the structure, process and outcomes of nursing care. The structure of nursing care is indicated by many factors such as supply of staff, education level and quality of care provided. Process indicators measure aspects of nursing care such as assessment, intervention, and RN job satisfaction. Patient outcomes that are determined to be nursing sensitive are those that improve if there is a greater quantity or quality of nursing care (Nursing world, 2013). In 1999, the American Nursing Association recognized a total of 10 indicators that apply to hospital based nursing care (Americansentinel.edu, 2017). Indicator such as pressure ulcers, patient falls and nosocomial infections are recognized in this list and are considered preventable with proper nursing action. Knowledge of these indicators could have assisted the nurses in several ways involving this case study involving Mr. J.

physical abuse may result in a hip fracture).Individuals who experience physical abuse often get threatened, harassed and as a result of this abuse they often experience emotional stress such as worry, depression, shame, guilt, isolation, low self-esteem post-traumatic stress syndrome or anxiety. These signs may be prolong and contribute to memory loss or other illnesses. An older adult may also feel shame, guilt, or embarrassment that someone in the family or someone close has harmed them and therefore they wouldn't want to disclose or share this information with anyone, in the case of. Some abused older adults may start to eat less, use more medications or drink more alcohol to help cope with the emotional and physical hurt. They may have difficulty sleeping or sleep too much. Some abused elderly individuals may have a decreased social life and therefore loose interest in life or become withdrawn (disengagement theory) and some may have suicidal thoughts.

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

Institutional abuse is a type of systematic and organised abuse that mostly goes on in residential and hospital settings However, individuals can be abused in many other ways in settings where they could expect to be cared for and protected. For example:

Two types of data were collected through surveys, both before and after implementation of the combined approach (Sand-Jecklin and Sherman,2014). The first data was on nurses’ point of view with regards reporting process, and the second on patients view regrading nursing care. The baseline survey included 233 patients and 148 nurses, while the survey three months into the implementation period included 157 patients and 98 nurses. The final survey, 13 months into the impanation, was completed by 154 patients and 54 nurses. The patient survey also included responses from patient families. These were 70, 72, and 53 responses for baseline survey, three-month postimplementation surveys, and 13-month postimplementation surveys.

The patient is a 45 year old man who had GI surgery 4 days ago.  He is NPO, has a nasogastric tube, and IV fluids of D51/2saline at 100 mL/hr.  The nursing physical assessment includes the following:  alert and oriented; fine crackles; capillary refill within normal limits; moving all extremities, complaining of abdominal pain, muscle aches, and "cottony" mouth; dry mucous membranes, bowel sounds hypoactive, last BM four days ago; skin turgor is poor; 200 mL of dark green substance has drained from NG tube in last 3 hours.  Voiding dark amber urine without difficulty.  Intake for last 24 hours is 2500mL.  Output is 2000mL including urine and NG drainage.  Febrile and diaphoretic; BP 130/80; pulse 88; urine specific gravity 1.035; serum

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.

I enjoyed reading your post. I agree that when conducting a comprehensive assessment, it depends on what area of the hospital you work in. I work in the PACU, assessing a patient is much different than when I worked in the ICU. When I worked in the ICU, I would gather the necessary information from the ED and conduct my initial assessment based on prior documentation. I would do a complete head to toe assessment and physical assessment. For example, assessing a patient’s skin completely for pressure ulcers was mandatory. Working in the PACU, our patient usually receives a telephone interview prior to their surgery, which entails obtaining medical and surgical history, medication, support systems, allergies, living arrangements, etc.

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

Elder Abuse is defined as any activity performed by an individual whereby these actions cause suffering of the older adult, intentionally or not (Touhy, Jett, Boscart & McCleary, 2012, p. 378). Unfortunately, the incidents of elder abuse continue to rise with the increasing number of people entering older adulthood. It is interesting to note that although elder abuse is highly under reported its occurrence increased three fold over a ten-year period (Friese & Collopy, 2010, p. 61). Certainly, it is a nurse’s duty to provide holistic care to his or her patients, which must include protection from abuse. Elder abuse can take on many forms including physical, emotional, sexual, neglect and financial. It is important to note that for the

This concept is taken from Block 4, Module 6 which is entitled as ‘Assessment of respiratory system’. The respiratory system comprises of different organs used in respiration. Respiration involves inhalation and exchange of oxygen and carbondioxide between living organisms and the environment. The organs of respiration include; the nose, pharynx, larynx, trachea, 2 bronchi, bronchioles, 2 lungs and muscles of breathing (the intercostal muscles and the diaphragm).