Systematic Nursing Assessment Case Study

By carrying out an assessment nurses can identify the causes of problems that require medical involvement. Nettina (2006)

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.

Through basic observations, health professionals are able to evaluate the performance of an individual’s health status. In relation to Casey, it is noted in her Observation Chart that in the time span of two hours the patient’s health status had changed from being relatively normal (to the patient) to an increased respiratory rate, heart rate and temperature as well as a decrease in blood pressure. It is also noted that the patient has a score of 8 in the pain scale (compared to the score of zero two hours previously), relating to the lower abdomen. Programs such as Between the Flags acknowledges the fact that the early recognition of deterioration of patients can reduce harm to patients through designing and implementing systems which provide a structural response in the event of a deteriorating patient, such as Rapid Response and Clinical Review. There are two phases involved in the rapid response, which includes the afferent phase and the efferent phase. The afferent phase focuses on the overall monitoring and recognising the deteriorating patient whereas

An evaluation of Mrs Smith circulation was the next step carried out by the nurse, as in the breathing assessment Mrs Smith pallor was noted as being flushed and the patient appeared confused this could be associated with poor cardiac output. The nurse recorded the patient’s blood pressure using a dinamap it was measured at 88/50, it was then rechecked manually to ensure accuracy. The pulse was checked manually for rate and rhythm it was recorded as 98 beats per minute. Capillary refill was checked, was found to be normal.

The purpose of this paper is to conduct an in depth exploration of the nursing care considerations of patients in a specific clinical area. Through the synthesis of prior knowledge, clinical experiences and skills, evidence based best practices, and care of patients a comprehensive care and teaching plan will be composed. Integration of critical thinking and clinical reasoning skills, combined with evidence-based research will provide confirmation of nursing process comprehension. The inclusion of reviewed literature will further support knowledge and understanding.

The ASPIRE framework, also referred to as the nursing process (Barratt, Wilson and Wollands, 2012) was used to structure and develop Susan’s care plan. Introduced by Barrett, Wilson and Wollands (2012), following on from APIE developed by Yura and Walsh (1967), ASPIRE stands for assessment, systematic nursing diagnosis, planning, implementation, recheck and evaluation. Hogston and Marjoram (2006) believe that systematic nursing diagnosis was added to offer direction and time for the nurse to reflect on gathered information and systematically develop a diagnosis. Also the aspect of rechecking is to enable the nurse to monitor and plot a patient’s progress contributing to the final stage of evaluation of care and if its successfulness (Barratt, Wilson and Wollands, 2012).

Pulse oximeter used to check his oxygen saturation level, which was 98% on air with no central or peripheral cyanosis. Since Mr Devi, does not seem to have any sign of abnormal respiration. The next assessment is circulation, where there are many physical signs to look for. The colour of the hand and digits, are they blue, pink, pale or mottled. Also need to measure for capillary refill time (CRT) by applying cutaneous pressure for 5 Sec on a fingertip held at heart level of Mr. Devi. The normal value of CRT is usually less than 2 second prolonged CRT suggests poor peripheral perfusion. Measure his Blood Pressure (B/P), count pulse rate by listening to the heart with a stethoscope or palpate peripheral and central pulses, assessing for the presence, rate, quality, regularity and equality. All of this assessment indicates the cardiovascular system in the patient is within the normal range or is there any emergency measures should take (Resus.org.uk 2016). However, Mr Devi’s circulation is a concern because his HR was 110bpm which is higher than normal range, the normal heart beat for adults ranges from 60-100bpm. Also his BP was 190/99mmhg with mean arterial pressure (MAP) of

The Joint Commission. (2015, June 3). PC.01.02.03: The Hospital assesses and reassess the patient and his or her condition according to defined timeframes. Retrieved from The Joint Commission:

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.

Nursing care is focused on the assessment, nursing diagnoses, planning, implementation, and evaluation of patients. This nursing process can also be implemented in aspects outside of nursing and on the nursing field as a collective group. The nursing role is evolving, following the process the outcomes have to be evaluated and put into perspective. Research is being completed the conclusions are all the same, the higher education of nursing care the better the patient outcomes.

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 pulse is an indication of an individual’s heart rate. When checking for a pulse in the primary survey, begin with palpating the patient’s radial or carotid artery (Basic Patient Care 2012, p. 50). This may reveal a normal (60-100 beats/min), tachycardia (<100 beats/min), bradycardia (> 60 beats/min) or asystole heart rate. Additionally, the capillary refill may also provide details about a patient’s cardiovascular status. This is performed by applying pressure to the nail bed and calculating the time it to takes to refill to a normal color, which should take no more then a few seconds otherwise suggesting capillary closure (Mick J Sanders, 2012, p. 1400). An additional accessory to Circulation is Hemorrhages, these involve more through examinations of the pulse, blood pressure and warmth of peripheries of patients. Additionally, you must thoroughly look for indication of bleeding, specifically in the areas around the chest, abdomen and externally seen by the eye.

This stage is when the patient first hears about his/her illness, and this is where the patient is saying &quot;no, not me&quot; and &quot;it can't be me&quot;. During this time they will also ask a numerous amount that &quot;is the results wrong&quot;, or &quot;could you check my results again please&quot;.

A complication from a MI is cardiogenic shock, it is rare but is life threatening when not treated early. Even if Mr Jones is treated for cardiogenic shock early, there is only a fifty percent survival rate (Mayo Clinic Staff, 2014). Signs and symptoms the RN should be aware of for cardiogenic shock include increased respiration rate, shortness of breath, tachycardia, weak pulse, pale skin, jugular vein distension cold hands and feet and decreased urine output. This is due to the heart being damaged and unable pump enough blood to supply the required amount oxygen to the body (Lemone et al., 2017). The RN can increase Mr jones oxygen rate to improve the amount of oxygen being delivered to organs, also maintain the high-fowlers position for