OMEAGE-7: Evaluation Of A Patient

Clinical practices are standardized using a newly developed nursing tool to capture and summarize information before the patient enters the exam room. Tracks performance using an “all-or-none bundle approach.” Bundle Example for

9. The review of systems (ROS) is documented for patient care purposes and also factors into the ________________ for the patient 's visit.

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.

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.

Answer the following patient information questions using the table provided. Refer to figure 4-10 on p. 83 of Health Information Technology and Management for assistance.

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 topics were grouped together so that it flowed logically together and the nurse only needed to indicate negative exceptions to a healthy assessment. This would also minimize charting and clarify problematic areas in the patient’s assessment. If a section was normal, a quick check box indicating “no problems noted” was provided.

The evaluation of the nursing process is demonstrating the understanding of how to asses a patients overall life by using the 6 holistic approaches towards nursing which are; social, cultural, spiritual, developmental, physical and psychological. The 6 holistic approaches towards nursing are used for the nursing assessment phase within the nursing process to identify all key aspects of assessment and the skill of not just assessing someone on their physical wounds but also their wounds you as a healthcare worker may be unable to identify visually. The National Board of Nursing and Midwifery explains that all nurses and midwives are responsible for a patient’s level of care whether it be physically or any other 5 of the holistic approach to the nursing assessment (NMBA, 2006). Using the holistic approach towards nursing assessment doesn’t necessarily mean that the health care worker has to formally write down a nursing assessment it can simply be done when a healthcare worker is washing a patient, feeding a patient, giving medication and more, this is why a nursing assessment using the holistic approach is the most effective way to conduct a nursing assessment.

The Geriatric Institutional Assessment (GIAP) Profile relates to staff awareness of existing programs and protocols at your institution, that support nursing staff who are caring for the geriatric population. There is a section on the GIAP which drills down on specific care regimens that should be part of routine patient care, for patients with confusion, patients at risk for falls, or those at risk for pressure ulcers

Assessment is described as”The first stage of the nursing process, in which data about the patient’s health status is collected” (Oxford dictionary of nursing, 2003, p23), following this phase a care plan can be devised.

Assessment of a patient is a big process of decision making, it is about the collection of information which will contribute to an overall judgement of a person and the illness they may have. Lloyd (2010) states that assessment is one of the first steps which is needed to be done in the nursing process, it is a building block for a relationship and an ongoing process which lets health professionals gather the correct information to help them understand the problems and needs that the patient is going through. Most of the nursing assessment which are in use today will all have very similar aims. The difference is that how the assessment’s are carried out is where the differences come from.

Assessment is the accurate collection of comprehensive data pertinent to the patient’s health or the situation (“American Nurses Association,” 2010). Assessment is the first step in the nursing process and the most important. Assessment is the accurate collection of the patient’s health date

The purpose of a nursing health assessment is to collect holistic, subjective and objective data to determine a patient’s overall health and well-being to establish a professional clinical judgement. The nurses collect physiological, psychological,

The head to toe physical assessment is the first step of the nursing process and is a systemic approach of collecting objective (physical) and subjective (mental) data on the patient that will help the nurse formulate nursing diagnoses and plan patient care. It is also used to confirm or question data that was stated in the pt. previous history stated in the charts and to evaluate the effectiveness of the nursing interventions that were carried out on the patient. The main focus of the head-to-toe assessment is to focus on what the patient is currently presenting with; the patient's responses to actual or potential problems.

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