Assessment Of Patients Via Nurses Case Study

Introduction: Assessment of Patients Via Nurses

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Assessing a patient's issues, needs or problems is very basic for health care proceedings; it is an integral part of the treatment or providing required service to a certain patient. It is also important as it helps in ensuring patient's health-wise safety during the appointment. Also, each of the practices associated directly or remotely with the assessment process is dedicated to maintaining safety, and mitigate the scope of any injuries or accidents. In the case of nursing assessment, the practices include performing a medical history background check and then conduct specific physical exams, these exams are not just to detect the relevant symptoms, it also helps in ensuring that no potential medical risk would predispose while the actual procedure or surgery will take place relevant to the medical emergency or requirement. Also as the Nurses are the key elements of providing the required care, assessment helps them in forming a care plan and to plan that the nurses need to examine the patients holistically and then detect their actual needs. Also, nurses proceed by assessment as it helps them in incorporating the recognition of abnormal versus normal body physiology.

As it is mentioned that the assessment is the most basic and integral part of the primary care plan and with the implementation of the care plan and with the help of devising strategies the patient would be able to cope up with the symptoms and overcome the respective physical or mental barriers. Also assessing patients is a very regular task, as it can help the nurses to keep track of the progress and the impact of the care plan and according to those reviews, they can revise the care plan and perform a further deep assessment of patients medical condition or situation.

Evaluation is also very vital in the context of healthcare, as it focuses on the evidence-based approach towards the practice delivery (Moule et al. 2017). It can provide the most accurate judgment on the ongoing procedure and identify the aspects which are working as well as the ones which are not working, this is how the nurses can revise their care plan and make the necessary adjustment. Also, it helps the nurses in providing their judgment or opinion about the effectiveness of the treatment or services provided to the patient towards their superior, mostly to the doctor.

Main Body

This report is going to discuss the implementation of underlying concepts and strategies within the assessment of the patients by the nurses, also the report is going to interpret how the assessment process helps in providing the care plan and how the knowledge of physiology, anatomy, the pathophysiology of a respective professional nurse can help him or her in assessing the patient needs and imply care plan (Zeid Abadi et al. 2017). To make the report more accurate and specific this report is going to provide those above-mentioned insights in regards to two specific case studies from two different patients

Patient 1:

Introduction of the patient

The first case study is about a woman, from chesterfield. At the time of the assessment, she is 34 years of age and a single mother. She is not on any medication and also she is physically very fit and well, her weight is just above the average, nothing to worry about in that part. Also, vocal background checks up provided information like, she have not been majorly sick for a while, no history of major accidents or incident which can physical hurt her (Rachel et al. 2019). She is unaware of her allergies, or whether she has any. She is a single mother to two children, of the respective ages of three and five. Also by profession, she is a teacher. She teaches children in a local primary school. So it is evident that her life is stressful, as it takes a lot of effort and time to take care of two kids, specifically kids under six years of age and she also has to manage her work and in work also she has to take care of class full of kids.

Although physical stress is not the key problem, the patient is struggling to live her daily life and her mental health is deteriorating.

Methods and tools used

As it is very evident from the previous medical history and her statements that the woman does not have any physical health condition. Some of the issues she is facing could indeed be associated with physical conditions, such as feeling tired, this can be hormonal like some the haemoglobin level can influence people's sleep or thyroid hormones can cause influence too (Bdair and Maribbay, 2020). Although after the primary conversation the preferred tools or methods for accurate assessment would be, first there would be some physical examination and relevant blood tests, so the presence of any physical illness can be eliminated completely and the focus could be on the mental condition of the patient. In this case, the preferred tools would be

• Questionnaires: some basic questions along with some specified questions would be included in this, the questionnaires would not be long or descriptive instead they would be to the point and include few yet major questions. Sometimes patients are going through some metal deterioration but fail to recognise or mention all the symptoms, questionnaires help in assessing the exact symptoms and identify the issues she is having (Baker et al. 2020). The questionnaires will include questions such as; about her daily routine, when did she feel low, which regular tasks makes her feel tired, what kind of negative thinking crowds her mind, what is her attitude towards her family, which part of the day she enjoys, what is her take on her profession, what is the entertainment measure of life, etc.
• Observation and standardized tests: Observations are the most integral skills required to assess the mental conditions within a patient. Nurses can use interviews and forge the interview sensitively so that the patient will open up and also use effective communication skills such as; active listening, all of these need to be analysed by professional observation and then conduct some standardised test, so it will identify the prominent mental issues faced by the patient. The standardised tests include testing their stress level or testing their vulnerability and interviews started with active listening and the nurses require to stay calm and composed during her narration of their problem, and also the patient needs to be provided an emotional space and make them feel heard through the active listening skills (Poorchangizi et al. 2017). The information from these basic conversations needs to be analysed and then the standardised test and with the help of professional observation the symptoms would be identified and the nurses can assess a few mental conditions relevant to the patient.
• Rating scale and Checklist: As mental conditions have very wide contexts, such as depression have different categories and in accordance with the gravity of the disease, the treatment is preceded. That is why the checklist is important it consists of the basic tasks and correlated durations and willingness, these things are filled up with the help of the patient's given information and based on the results of the standardised test results along with considering the observational findings from the interview or conversation with the patient. In this case, her records will be filled within checklists associated with some major mental health illness symptoms, just as to get the lucid conditions of where she is standing in regards to chronic insomnia, the checklist will include some sleep-related aspects such as; duration or the frequencies or is it deep or very light and also checklists can be forged in order to perform comparative observations like the checklist can provide a lucid image of the previous behaviours along with the present conditions of the patient in that similar context (Giske and Cone, 2020). Also as so far the symptoms are more or less identified so the checklists could be designed to understand the frequencies or gravity of those symptoms and as many mental conditions show similar traits or symptoms this will help in to recognise the most dominant one or the one which helps in originating the others, such as sometimes depression can help in developing insomnia or loss of self-confidence can cause anxiety so checklist should be able to help the nurses in assessing the accurate symptoms and the originating or the dominating mental health illness. Also, one of the most important checklists is correlated with the rating scale, and as it mentioned that mental conditions have level and the treatments need to be specific to the level, so her symptoms and the potential illness or reactions all should be rated accurately (Broekema et al. 2018). This rate list helps in assessing the patient's standing or situation within a mental health context, it is very vital as it helps in designing the specific care plan from the nurses perspective also will help in evaluating the condition and convey relevant and important information to the superiors or in this case to the professional psychologist or psychiatrist and they will not have to determine the problem instead they can start working on solving these issues and even in the solution or treatment the assessment helps (springer.com, 2019).

Identified care need (Knowledge-based)

As the methods and tools would be adequate to recognise the symptoms and associated diseases. In this case, the woman is facing many problems and her daily tasks are becoming a burden for her, so the conversation or interview is not easy to analyse and utilise the problem. Instead, effective communication and active listening help her in trusting the process and open up (Pölkki et al. 2018). Then with the help of observation and tools like a checklist and standardised test it becomes identified that she needs professional help, the basic knowledge of psychology helps in detecting the disease from the potential symptoms, such as; excessive sadness, unable to find peace, or happiness within anything, anxiety within familiar places, even between closed ones, feeling tired or unwilling to do anything, crying all day. All these symptoms and the knowledge can help the nurses to assess that she is going through post-traumatic disorder after she lost her loved one suddenly. She requires proper treatment in form of consultant and psychologist sessions and medication in regards to major depression, panic disorder, anxiety disorder, chronic insomnia.

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Potential Problem

The potential problem regarding this case study is that the patient is not clear about her own answers, only thing that is clear that she fails to cope up with her loved one’s death and now she fails to do anything from her daily routine in normal manner. Although assessment helped in understanding the symptoms, but as they are so many and related to myriad mental illness, that from a nursing perspective, it became complex to focus on too many diseases and complete the assessment.

Assessment process

As it is mentioned that even after making the conversation as a safe place for the patient, in this case, the patient is going through a wised range of negative emotions and going through many symptoms so it is hard to assess the accurate and specific ones, as all of them are co reacted but still with tool and observations such as questionnaires helps in assessing that she feels tired all the time but she can barely sleep and also observation helps in assessing the tiredness within her so it makes it easy for the nurse to assess that she is experiencing insomnia and the checklist confirms it and rate scale suggest that it can be acute or transient insomnia (Skog et al. 2020). Also, the observation and checklist help in understanding how the present loses all her will to perform her basic daily tasks and also standardised test result suggested that she is extremely upset from her loss and still stand on the same ground and all of these suggested that she is going through post-traumatic conditions and rating scale helps in detecting the major depression. These assessments then can be passed as integral information about the patient and further treatment can be specific to her issues (aacnjournals.org, 2020).

Patient 2:

Introduction of the patient

For this case study, the chosen patient is completely different and the problems faced by the patient are also very different from the previous one. This case study is about a 88 years of age Man from Bakewell. The patient lives on his own although he once had a wife and took care of her until she dies. Right now the most concerned family member of the patient is his daughter, who is the one who needs to be informed about the patient’s condition on daily basis and that is also a responsibility of health care professionals, mostly done by the nurses. He also has some problems with his hearing, his left ear is partially deaf, and wears a hearing aid (Kendall-Raynor, 2017). The patient has been admitted to the hospital via A&E within the acute medical ward. He had a terrible fall in his house. The patient was very confused during the admission, so his daughter helps in conveying some relevant primary information, such as the patient was an active human being, he loves gardening, and has a social life too. Although the biggest concerns are his age, the fall could have broken his bones and at this age, it is hard to recover from that, also one of the concerns is the patient's state of mind, as he is very confused and is not oriented to place, time or person. Also one of the important pieces of information about the patient is that he takes medication as "Calcichew D3 forte 500mg OD”, but he and his daughter also is unaware of any allergies. He however gone through a previous surgery of hip replacement for the left hip in 2011

Methods and tools used

At first, some baseline observation has been conducted on the patient with the help of basic tools such as;

• Oximeter and sphygmomanometer: Nurses can measure the oxygen saturation level with the oximeter and with the help of sphygmomanometer nurses measure the blood pressure (Vuille et al. 2018). These two are the most basic measurement along with height and weight is taken in case of accidental case, this helps in assessing the internal condition of the patient. Like in this case the results showed that the pressure is 188/73 which is on the higher side and which is obviously still the, the measurement will help in confirming that, and now the nurse will work to bring the in normal also sometimes people that age after the fall lose consciousness or can be experiencing short breathiness or difficulty in breathing but the oxygen saturation showed 98% which shows, the patient has the adequate amount and does not need any additional oxygen supply.
• “Heart rate monitors (HRM)”: It helps in measuring the heart rate or pulse, and this is also very vital as this kind of fall can influence heart complications such as; heart attack, although the pulse results are in sync with the blood pressure, the results show the pulse is 82 for the patient and that shows that the high blood pressure is influencing the pulse.

Also through the help of “Computerized Tomography (CT)” the nurses measure the BMI rate of the patient, it is not the most necessary but as the patient suffers from a fall injury, so surgery can take place as a potential treatment so BMI and all of those previously mentioned measurements are vital.

• Standard Conversation and Checklist: Standard conversation or interviews are also very important in the case of this kind of patient, with the help of this and the questionnaires it becomes easy to understand the previous diseases or incidents he goes through or why or how he falls so it would be easy to assess that it was an incident or some physical condition is the reason for the accident (Pölkki et al. 2018). In this case, as it is mentioned that the patient is very confused so it is making the patient more anxious and that can elevate his blood pressure more so to avoid that the questionnaires and active listening sensitively mitigate the anxiousness and then the nurses can further continue their primary assessment.
• Blood tests and X-ray: As the patient falls from a high place, and lost some blood too, so the nurse will assess the patient on some primary blood tests such as; hemoglobin, vitamin D levels. Also more importantly in fall cases, the nurses will primarily take care of the wound and then run x-ray on the wounded area of the patient, also of the chest region Also as the patient's bone does not look broken so the nurses will use TUG or "Timed UP and Go" assessment with the help of a chair. Also an MRI and CT scan help in assuring the wound's impact within the brain region specifically (Olufunke, 2018). Also, the patient’s blood has been sent for the test blood count (WBC, RBC, and Platelets)
• Thermometer: Sometimes in case of fall incidents the patient can develop mild to strong fever and fever can impact the patient's other health-related aspects and cause harm to the ongoing assessment process too, so it is vital too, in this case, the temperature of the patient is 36.9, which is not worrisome or capable of impacting the further assessments (wiley.com, 2017).

Identified care need (Knowledge-based)

In this case, the assessment is dependent on most of the tests; most of the tests provided a baseline observation which includes Blood pressure, pulse, oxygen saturation, BMI, and temperature. These are remotely connected with the fall, and the direct assessment, in this case, is connected with the bruises in the face, and those need to be cleaned and stitched in some places. Although this is only based on the results from baseline observation (Ng and O’Brien, 2017). Then the behaviour of the patient shows some frequent and familiar symptoms associated with Alzheimer’s disease and with the help of previous medical history it is confirmed that he is suffering from Alzheimer's disease. Although the primary care the patient needed is some medication to relieve the pain, stitches in the face, and medication for lowering the blood pressure and complete rest. Also, the medication used by the patient is "Calcichew D3 forte 500mg OD” which helps in preventing vitamin D deficiency. Thus assessment can surely predict that calcium deficiency can be one of the reasons behind the fall, however, the care plan would include providing medicine for potential osteoporosis, and calcium-rich medication would also be prescribed.

Potential Problem

The most common potential problem within this is that the patient was very confused during his admission, and as he is a fall patient, the nurses needs to investigate lots of basic queries and the patient was unable to cooperate, although the external wounds are limited to his face so the wounds can be cleaned and stitched up, but the test results shows that the man is suffering from chest infection, which needed further attention, but the assessment become hard as most of it depends on the test results and due to the confused behaviour, the patient could not cooperate as much as a primary nursing assessment requires.

Assessment process

As this case is very different from the previous case, in this case, the fall does cause some wounds but the assessment can not just focus on those, it requires a lot of test results which include x-ray and blood test results. That is why at first the assessment is limited about the wounds, and mostly based on the baseline observations, such as the elevated blood pressure (Olasoji et al. 2017). Then the previous case history is assessed critically and the medication for calcium deficiency is recommended as part of the care plan. Also, the X-rays suggest that the patient has chest infection so that becomes the biggest finding from assessing the patient and it would be a great help in further treatment of the patient, as well as the other assessed baseline information can guide the future treatment too (wiley.com, 2020).

Conclusion

The report has already gone through how assessing patient is the most basic part of primary care. The report critically presented the importance of assessing the patients. As it is mentioned that the patient is most of the time unaware of the specific problems even they can not always state the symptoms so it is important for the diagnosis that the nurses do some primary assessment, this helps in forging the further care plan. This care plan considers all the direct and remote aspects the nurses can find through their primary assessment. To provide a lucid image of the procedure and how that impacts detecting the diseases and designing the care plan, this report critically analyses two case studies (Mwebe, 2017). In these two case studies the report focuses on two patients and the case studies are ideal for the cause as they cover a wide range of the respective context in regards to assessing patients, First of all, both the patient's problem belongs to two different categories, one is suffering from mental illness and other is suffering from physical problems. Both are different from each other in regards to their demographic characteristics, such as; age and gender. Also one of them has barely any medical history and the other has a rich medical history so it helps the report is showing how the nurses need to consider different aspects and also how myriad tools and methods are used to assess the patient. This fulfils the first learning outcome, as this is how in these two cases, the respective nurses uses their conceptual ability to assess the patient primarily. Also, the report covers the discussion on how the results from those professional observations, reviews, and evaluations help in forming a plan for care specific to the respective patient and the plan is designed following the assessment and professional judgment. This is how the respective nurses fulfil the second learning outcome as they interpret their evaluation of patients and prepare care plan. At the end the knowledge of psychology for the first case study and knowledge of physical anatomy helped in understanding that the first patient is suffering from depression and the second patient have wounds in his face and have chest infection too, this is how the third learning outcome fulfils. In the conclusion this report is going to state that assessing the patient is not just a vital part the whole treatment process starts with this step, this saves time in further treatment and also guides the further treatment in a certain direction, that is why assessment of the patient is important and useful for the sake of the patient as well as for the future treatment process.

References

Journals

• Baker, K.M., Vragovic, N.S. and Banzett, R.B., 2020. Intensive care nurses’ perceptions of routine dyspnea assessment. American Journal of Critical Care, 29(2), pp.132-139.
• Bdair, I.A. and Maribbay, G.L., 2020. Perceived knowledge, practices, attitudes and beliefs of Jordanian nurses toward sexual health assessment of patients with coronary artery diseases. Sexuality and Disability, 38, pp.491-502.
• Bingham, H. and O'Brien, A.J., 2018. Educational intervention to decrease stigmatizing attitudes of undergraduate nurses towards people with mental illness. International Journal of Mental Health Nursing, 27(1), pp.311-319.
• Broekema, S., Luttik, M.L.A., Steggerda, G.E., Paans, W. and Roodbol, P.F., 2018. Measuring change in nurses’ perceptions about family nursing competency following a 6-day educational intervention. Journal of family nursing, 24(4), pp.508-537.
• Giske, T. and Cone, P., 2020. Comparing Nurses’ and Patients’ Comfort Level with Spiritual Assessment. Religions, 11(12), p.671.
• Kendall-Raynor, P., 2017. RCN toolkit for school nurses. Nursing Standard (2014+), 32(6), p.15.
• Mwebe, H., 2017. Physical health monitoring in mental health settings: a study exploring mental health nurses’ views of their role. Journal of Clinical Nursing, 26(19-20), pp.3067-3078.
• Ng, Y.P., Rashid, A. and O’Brien, F., 2017. Determining the effectiveness of a video-based contact intervention in improving attitudes of Penang primary care nurses towards people with mental illness. PloS one, 12(11), p.e0187861.
• Olasoji, M., Maude, P. and McCauley, K., 2017. Not sick enough: experiences of carers of people with mental illness negotiating care for their relatives with mental health services. Journal of psychiatric and mental health nursing, 24(6), pp.403-411.
• Olufunke, O.D., 2018. Factors associated with utilization of pain assessment tools in pain management among nurses in selected hospitals in ekiti state. International Journal of Caring Sciences, 11(1), pp.163-170.
• Pölkki, T., Korhonen, A. and Laukkala, H., 2018. Nurses' perceptions of pain assessment and management practices in neonates: a cross?sectional survey. Scandinavian journal of caring sciences, 32(2), pp.725-733.
• Pölkki, T., Korhonen, A. and Laukkala, H., 2018. Nurses' perceptions of pain assessment and management practices in neonates: a cross?sectional survey. Scandinavian journal of caring sciences, 32(2), pp.725-733.
• Poorchangizi, B., Farokhzadian, J., Abbaszadeh, A., Mirzaee, M. and Borhani, F., 2017. The importance of professional values from clinical nurses’ perspective in hospitals of a medical university in Iran. BMC medical ethics, 18(1), pp.1-7.
• Rachel, H., Chiara, C., Robert, K. and Francesco, S., 2019. Spiritual care in nursing: an overview of the measures used to assess spiritual care provision and related factors amongst nurses. Acta Bio Medica: Atenei Parmensis, 90(Suppl 4), p.44.
• Skog, N., Mesic Mårtensson, M., Dykes, A.K. and Vejzovic, V., 2020. Pain assessment from Swedish nurses' perspective. Journal for Specialists in Pediatric Nursing, p.e12317.
• Vuille, M., Foerster, M., Foucault, E. and Hugli, O., 2018. Pain assessment by emergency nurses at triage in the emergency department: A qualitative study. Journal of clinical nursing, 27(3-4), pp.669-676.
• Zeid Abadi, M.R., Ghazanfari, Z. and Roudi Rasht Abadi, O.S., 2017. Correlation between knowledge-skill and the importance of physical assessments in nurses: A descriptive correlational study. Journal of hayat, 23(1), pp.86-99.

Online Article

• aacnjournals.org, 2020, Intensive care nurses' perceptions of routine dyspnea assessment, Available at, https://aacnjournals.org/ajcconline/article/29/2/132/30849/Intensive-Care-Nurses-Perceptions-of-Routine[Accessed on 24.07.2021]
• springer.com, 2019, perceived knowledge, practices, attitudes and beliefs of Jordanian nurses toward sexual health assessment of patients with coronary artery diseases, Available at, https://link.springer.com/article/10.1007%2Fs11195-020-09639-y[Accessed on 24.07.2021]
• wiley.com, 2017, Pain assessment from Swedish nurses' perspective, Available at, https://onlinelibrary.wiley.com/doi/full/10.1111/jspn.12317 [Accessed on 24.07.2021]
• wiley.com, 2020, Pain assessment by emergency nurses at triage in the emergency department: A qualitative study, Available at, https://onlinelibrary.wiley.com/doi/abs/10.1111/jocn.13992[Accessed on 24.07.2021]