The more detailed and comprehensive an assessment is, the better understanding we have of our patient’s and the plan of care that we will follow to ensure they are taken care of. After reading this article, I have a deeper insight into understanding the need for a structure when performing a health history. The detailed descriptions that were provided will enable one to use the specific examples when questioning a patient, ones on which I plan on implementing in my practice. I found this article very well written and explained thoroughly, as it is a great representation of a well-completed history. In my daily practice as a nurse, I follow a specific format for completing a patient history and assessment; it very closely resembles this model. I find that when initiating a patient’s history, I begin with asking all pertinent questions in relation to presenting problems, and all historical information. I then follow with a hands-on assessment, I listen to breath sounds and heart rhythms while asking questions related to those particular body system. Listen for intestinal sounds when asking questions about dietary habits. I engage the patient in their assessment so they feel a sense of trust and willingness to cooperate in their care. I believe that more articles could be written about performing a…
ASSESSMENT: Obtaining, validating, and communicating subjective and objective client assessment data including patient history, consultations, lab findings, pharmacological requisites, and the nurse’s physical examination. Also involves the nurse’s determination of the congruency between the client’s needs and the ability of health care team members to meet such needs.…
Assessment is a vital aspect of nursing care. Assessment is the first phase of the nursing process. A thorough assessment involves gathering information and data about and related to the patient. The data that is collected includes physiological, psychological, environmental, sociocultural, economical, spiritual, and developmental history of the patient. Data may be objective or subjective. Objective data refers to the measurable and observable signs, such as the patient’s heart rate, blood pressure, oxygen saturation, temperature, facial expression, gait, color, etc. Subjective data is obtained from the patient himself and it is the patient’s account of their…
What other information would you like to learn during the interview with the family? What questions would you ask?…
Aylott, M. (2006a) ‘Observing the sick child: part 2a respiratory assessment’, Paediatric Nursing, 18(9), pp. 38-44.…
Nursing is concerned with human responses as they relate to the person’s environment whether it is in the hospital or in the community. With the help of the nursing process, nurses assess the person’s environment through the collection of subjective and objective data, perform risk assessments, identify safety hazards, and implement safety practices that will improve the patient’s health status and prevent further injury or…
Nursing Process: a method of collecting and analyzing clinical information with the six main components…
Throughout this piece the writer will discuss the fundamentals of nursing (primary,secondary and tertiary care) when assessing Mr Murphy who is a seventy two year old gentleman recently discharged home from hospital on oxygen, post an exacerbation of his chronic lung disease. The assessment setting takes place within the commuity where the comunity nurse plays a pivotal role in assessing both Mr Murphy and Mrs Murphy within their home. This is appropriate due to Mr Murphy not being the only person who will suffer from psychological and physical hardship during this time in life.…
It is important to know if the patient can function independently is in the area of taking their medication. Gathering information related to the patient nutritional status is also very important when gather of assessing information. Gathering information allows the nursing staff the opportunity to know when it is appropriate to make the necessary referral. For example, if patient has poor nutrition would be appropriate for the nursing staff to consult a doctor of nutritionist.…
The nursing role in health assessment involves a systematic collection of data that provides information to facilitate a plan of care to deliver the best care for the patient. Assessment is the foundation of nursing practice. The nurse carries out health assessment to determine the patient 's condition of health, risk factors, as well as the need for health education in order to develop an individualized care plan. The nurse oversees the holistic care of the client, which integrates the physical, emotional, cultural, and spiritual as well as the environmental elements affecting the patient (Hogan-Quigley, Palm, & Bickley, 2012).…
I would being by asking Mr. and Mrs. Lawson basic questions concerning the family’s history regarding any similar symptoms that other family members may have displayed. I would also ask if there were any changes in the family setting, such as relocating or if other family members have recently relocated. I would also ask Mr. and Mrs. Lawson specific details about the symptoms regarding Clara’s eating patterns, and sleeping patterns, and how long this has been occurring. I would also engage Clara into conversation, so that her direct responses could be included in the conversation, so that I would have a better understanding on the lack of eye contact when talking.…
The use of Roper, Logan and Tierney’s Activities of Living (2001) will be used as the nursing model in this essay, it is appropriate for use as this model was the one used by the nurses in the hospital to ensure holistic care of the patients. This nursing model has been adapted by the recovery nursing staff, for use in the initial recovery phase of this patient’s stay in hospital. The nursing assessments used will first be discussed, and a problem that the patient faced will be identified. The care that the nurses provided for the patient regarding this problem will then be analysed using relevant up-to-date literature.…
Mr. and Mrs. Lawson brought their 4-year-old adopted daughter, Clara, to see Dr. Mason, a psychiatrist. Clara was polite in greeting Dr. Mason, but did not smile and kept her gaze down as she took a seat. Mr. and Mrs. Lawson sat next to Clara and began explaining their concerns. They described Clara as a quiet child who has recently begun throwing temper tantrums, during which she is inconsolable. Her sleep and eating patterns have changed, and she no longer wants to go to preschool.…
The American Psychological Association defines assessment as ‘assess.(nd):to judge or estimate the value ,character ,etc of…’(Apa,2007). Whereas the (Oxford Dictionary for Nurses) defines it as ‘the first stage of the nursing process in which data about patients health status is collected and from which a care plan may be devised’.…
The assessment of patients forms a major component of the nursing role. It allows the nurse to gain vital information to base the planning and implementation of prioritised care on. A systematic method of assessment is required, that ensures that all areas of assessment are covered and that the assessment and subsequent interventions are as effective and efficient as possible. One method that can be followed for patient assessment is the primary and secondary surveys, with an additional assessment replacing the secondary survey post-operatively. This essay will display the implementation of these methods in the assessment of a trauma patient throughout the peri-operative period. The case study of Mrs Lily Flowers, as outlined in Appendix A, will be used to demonstrate the use of the primary and secondary surveys both pre and post-operatively, commencing with the pre-operative primary survey first.…