Then, I can be able to evaluate outcomes. During my assessment of Sara Lin, I was able to find out that she was experiencing a pain level of 6 and was having a hard time breathing. If I had not asked her and assessed her pain, I would not have found out that she was having a hard time breathing and that I needed to educate her about using an incentive spirometer to help ease her breathing, which I actually forgot to do during my first attempt at this scenario. During this scenario, I also learned how important patient education is to help my patient understand her situation and how she should properly care for her condition. For instance, I had forgotten during my first attempt to educate Sara about proper wound care. I realized how important it is to incorporate all aspects of her situation, not just how she is feeling pain and has a hard time hearing, but also to focus on her wound. If I had not educated her about wound care, then she would not know how to properly care for her wound, and this might lead to a risk of infection or bleeding and slow time
Clinical examinations offer significant chances for nurses to identify a suitable therapy association with their clients. Hence, the examination is seen as both interpersonal and intellect based activity. Assessments of sick people involve several steps. Screening examination helps gather necessary facts, analyses them and later group them into useful information. Potential analyses combine all possible examinations that associate with available information about a patient. Profound analyses focus most on data collection, analysis, and confirmation of potential examinations made. Nursing examinations as a step determine what symptoms identified deserves priority. All these steps aim at identifying problems and prioritizing those that need urgent medical attention (North American Nursing Diagnosis Association,
The patient is a 83 years old Caucasian female with a diagnosis of Generalized Weakness and Altered Mental Status. The patient is from home and lives with her daughter. She has a history of hypertension, arthritis, congestive heart failure, nstemi, and atrial fibrillation. First, I will obtain information from the patient’s daughter and collect data about the patient’s baseline and health history. Touhy & Jett (2012) mentioned the importance of assessing the physical, functional, social, and mental status in health and illness, which allows for comparison of patient’s baseline and adjustment of nursing care plan (p. 106). My plan is to do a comprehensive head-to-toe assessment, EKG, blood works, obtain specimen for ua/cs, and diagnostic
Evaluating a chronic pain condition from a biological perspective is limiting, and often fails to fully explain the patient’s symptoms. In contrast to the biomedical model, which explains pain purely in terms of pathophysiology, the biopsychosocial model views pain, suffering and disability, as the result of dynamic interactions among biological, psychological, behavioral, social, cultural and environmental factors. Consequently, assessment requires not only the examination of the biological dimension, but of the psychological and social dimensions as well. A patient’s experience of pain and response to any treatment for pain are affected not only by biologically determined nociceptive (nervous system transmission) processes, but also by psychological factors such as mood (for example, depression, anxiety) and appraisals (thoughts and beliefs about the pain), as well as by psychosocial factors such as the responses of others (for example, family, friends,
The concept assessment simply refers to an act of appraisal, evaluation and judgment (Dossey, Keegan, & Barrere, 2015, 469). In nursing care, assessment is the first crucial step that is carried out to be able collect and analyze information about a client. Assessment involves various issues such as physiological, psychological, spiritual, socio-cultural, life-style, and economic factors. This essay explores assessments in nursing practice and their importance in this field. It also covers models such as biopsychosocial, holistic, nursing process, and Ropers’ nursing model of the twelve activities of living.
Pain management for postoperative patients are a major problem that may cause prolonged treatment and rehabilitation costs, however, with the proper nursing strategy, it can be managed. In order to manage the pain, the knowledge of the causing event and the symptoms are necessary for the healthcare professionals. The assessment and measurement of pain in postoperative patients through their response can assist in increasing awareness regarding the specific causes of pain. The present study
Examination screening is an initial visit to Dr. X at Gottlieb Memorial Hospital. The length of the evaluation procedure will be approximately 45 minutes.
There are ranges of specialists who work on the rehabilitation team, each member of the team has a goal to help patient with a focus of promote QOL. The Case Managers are will be the primary contact person, with whom patient and family/caregiver can direct raise matters and ask for information. It is advised that a neuropsychologist should conduct a cognitive and behavioural/emotional assessment. Cognitive include perception and awareness, orientation, memory, though processing, problem solving, personality and decision making. Behavioural/emotional include emotional status, mood changes, adjustment difficulties, personality changes, inappropriate sexual behaviour, motivation level, substances misuse, depression, anxiety and psychosis. Nurses are involved with
Bedside reporting assist nurses with a chance to improve patient safety and increase patient collaboration in the arrangement of care. There is also less care correlated to inaccurate or deficiency of information because the report process includes actual patient apparition. Increased staff approval with bedside reporting supports teamwork and supports accountability.
When I do my assessment on admission, I always include the assessment findings that I expect to be abnormal if the patient has definite cardiovascular problem. I notify the MD and the nurse practitioner immediately if I find abnormal findings or values. I ensure to chart the education and the correction in response of the abnormal findings. In addition to that, tests and labs should be done to rule out problems. It is essential to know the patient’s health history before conducting the physical exam. I ensure to perform thorough cardiovascular and peripheral vascular assessments, and chart the findings clearly and in a timely manner. Discharge
The first goal of this training program is to teach a school psychologist in training all about assessment methods and protocols. Secondly, this training program will teach a school psychologist in training all about clinical diagnostics. This training program will be designed to help a school psychologist in training develop the appropriate knowledge and skills that are required to assess and diagnose a client. During this training, the trainee will learn the fundamental theories and principles of assessments to help the trainee recognize that there are various assessment methods that can be used to assess a client in this profession. Additionally, the trainee
"Medication errors results from the interaction of multiple factors that include regulatory environment, organizational leadership and commitment, management policies and procedures, complexity of tasks involved, work culture, and physical environment" (Chaudhury, Mahmood, & Valente, 2009, p. 229). Health care services that nurses perform in the hospital environments are physically and psychologically intense, which can potentially result in burnout, stress, and medication errors. Crowded and poorly designed work spaces are factors that contribute to staff stress, resulting in the risk of increase medication errors (Chaudhury et al., 2009). Ulrich, Zimring, Quan, Joseph, and Choudhary, 2004 (as cited in Chaudhury et al., 2009) "argued that reduction of nursing staff stress and error by physical environmental dimensions (such as air quality, acoustics, lighting, and so on) can have a significant impact on staff health and efficiency" (p. 230). There is limited research on the how physical environment affects medication errors. For this study, the research question was: "What is the nurses' perception of the role of the physical
The RN would first review the goals and outcomes of the patient care plan. The next step would be to collect Reassessment Data, " Assess the client response to the interventions."(pg. 128 Treas, Wilkinson) in which include vitals, auscultation of breath sounds, observation of activity, and asking the patient how they are feeling and family for observation. The RN would record the evaluation summary in the nursing note or care plan about the conclusion whether the outcome was achieved and the reassessment data supports the judgment. In order to revise a care plan, an RN must " review all the steps of the nursing process."(pg. 130 Treas, Wilkinson).
In the physical assessment a recent medical work up would be included because, for example irritability
Dorothea Orem was an extravagant nursing theorist whose theories were first published in 1971 (Dorothea Orem 's Self-Care Theory, 2014). Orem established several fascinating theories of nursing which are still are current in today’s nursing. Orem proposed three nursing theories that are identified as: self-care theory, theory of Self-care deficit and theory of nursing system (Dorothea Orem 's Self-Care Theory, 2014). Orem’s nursing theories are defined as a grand theory (Nursing Theories: An Overview, 2014). Grand theory is defined as an abstract outline under which the key conceptions and values of the discipline can be acknowledged (Nursing Theories: An Overview, 2014). Orem’s theories mainly proposed that